2016 Survey of Dental Fees Table of Contents

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2 Table of Contents General Practitioners National New England (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont). Middle Atlantic (New Jersey, New York, Pennsylvania). East North Central (Illinois, Indiana, Michigan, Ohio, Wisconsin). West North Central (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota).. South Atlantic (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) East South Central (Alabama, Kentucky, Mississippi, Tennessee).. West South Central (Arkansas, Louisiana, Oklahoma, Texas). Mountain (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming). Pacific (Alaska, California, Hawaii, Oregon, Washington). Specialists Oral and Maxillofacial Surgeons. Endodontists.. Orthodontists and Dentofacial Orthopedists. Pediatric Dentists.. Periodontists.. Prosthodontists.. Appendix Methodology.. Glossary. Survey Instrument Important Note: The survey data should not be interpreted as constituting a fee schedule in any way, and should not be used for that purpose. Dentists must establish their own fees based on their individual practice and market considerations. The American Dental Association discourages dentists from engaging in any unlawful concerted activity regarding fees or otherwise. Copyright 2016 American Dental Association.

3 General Practitioners - National D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0190 Screening of a patient D0191 Assessment of a patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0251 Extra-oral posterior dental radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 1

4 General Practitioners - National Percentile s Vertical bitewings - 7 to 8 radiographic D0277 images D0330 Panoramic radiographic image D oral/facial photographic image D0350 obtained intra-orally or extra-orally Cone beam CT capture and interpretation with limited field of view less than one D0364 whole jaw D0365 Cone beam CT capture and interpretation with field of view of one full dental arch mandible D0366 Cone beam CT capture and interpretation with field of view of one full dental arch maxilla, with or without cranium D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium D0417 Collection and preparation of saliva sample for laboratory diagnostic testing D0418 Analysis of saliva sample D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities D0470 Diagnostic casts D0601 Caries risk assessment and documentation, with a finding of low risk D0602 Caries risk assessment and documentation, with a finding of moderate risk D0603 Caries risk assessment and documentation, with a finding of high risk D1110 Prophylaxis - adult Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 2

5 General Practitioners - National Percentile s D1120 Prophylaxis - child D1206 Topical application of fluoride varnish Topical application of fluoride excluding D1208 varnish Tobacco counseling for the control and D1320 prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth Preventive resin restoration in a moderate to high caries risk patient permanent D1352 tooth Interim caries arresting medicament D1354 application D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral Amalgam - one surface, primary or D2140 permanent Amalgam - two surfaces, primary or D2150 permanent Amalgam - three surfaces, primary or D2160 permanent Amalgam - four or more surfaces, primary D2161 or permanent Resin-based composite - one surface, D2330 anterior Resin-based composite - two surfaces, D2331 anterior Resin-based composite - three surfaces, D2332 anterior Resin-based composite - four or more surfaces or involving incisal angle D2335 (anterior) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 3

6 General Practitioners - National Percentile s D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Resin-based composite - four or more D2394 surfaces, posterior D2520 Inlay - metallic - two surfaces ,029 1,100 1,189 1, D2543 Onlay - metallic - three surfaces 1, ,298 1, D2620 Inlay - porcelain/ceramic - two surfaces ,068 1,120 1,176 1,242 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,009 1,126 1,180 1,215 1,300 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,178 1,200 1,257 1,350 1, D2644 Onlay - porcelain/ceramic - four or more surfaces 1, ,200 1,245 1,311 1,395 1, D2651 Inlay - resin-based composite -two surfaces ,037 1,098 1,180 1, D2662 Onlay - resin-based composite - two surfaces ,041 1,088 1,161 1,207 1, D2663 Onlay - resin-based composite - three surfaces ,100 1,148 1,194 1,254 1, D2664 Onlay - resin-based composite - four or more surfaces D2710 Crown - resin-based composite (indirect) D2740 Crown - porcelain/ceramic substrate 1, D2750 Crown - porcelain fused to high noble metal 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 4

7 General Practitioners - National Percentile s Crown - porcelain fused to predominantly base metal 1, D2751 D2752 Crown - porcelain fused to noble metal 1, D2780 Crown - ¾ cast high noble metal 1, D2783 Crown - ¾ porcelain/ceramic 1, D2790 Crown - full cast high noble metal 1, D2794 Crown - titanium 1, ,325 1,365 1,400 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown D2929 Prefabricated porcelain/ceramic crown primary tooth D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2940 Protective restoration D2949 Restorative foundation for an indirect restoration D2950 Core buildup, including any pins when required D2952 Post and core in addition to crown, indirectly fabricated D2954 Prefabricated post and core in addition to crown D2961 Labial veneer (resin laminate) - laboratory D2962 Labial veneer (porcelain laminate) - laboratory 1, D2980 Crown repair necessitated by restorative material failure Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 5

8 General Practitioners - National D2981 D2982 D2983 D2990 D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 D3330 D3331 Percentile s Inlay repair necessitated by restorative material failure Onlay repair necessitated by restorative material failure Veneer repair necessitated by restorative material failure Resin infiltration of incipient smooth surface lesions Pulp cap - direct (excluding final restoration) Pulp cap - indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary and permanent teeth Partial pulpotomy for apexogenesis permanent tooth with incomplete root development Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) 1, , Treatment of root canal obstruction; nonsurgical access Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 6

9 General Practitioners - National Percentile s D3332 D3346 D3347 D3348 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior Retreatment of previous root canal therapy bicuspid Retreatment of previous root canal therapy molar 1, D3351 Apexification/recalcification - initial visit Apexification/recalcification - interim D3352 medication replacement D3353 Apexification/recalcification final visit D3355 Pulpal regeneration initial visit D3356 Pulpal regeneration interim medication placement D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery - molar (first root) ,109 1, D3426 Apicoectomy (each additional root) D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 7

10 General Practitioners - National D4212 D4240 Percentile s Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4241 D4249 Clinical crown lengthening hard tissue Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant 1, D4261 D4263 D4264 D4266 D4267 D4273 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant Bone replacement graft - first site in quadrant Bone replacement graft each additional site in quadrant Guided tissue regeneration resorbable barrier, per site , Guided tissue regeneration nonresorbable barrier, per site (includes membrane removal) ,000 1,049 1,133 1, Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position 1, ,004 1,200 1,250 1,323 1,400 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 8

11 General Practitioners - National D4275 D4277 Percentile s Non-autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft ,132 1,163 1,215 1,300 1, Free soft tissue graft procedure (including recipient and donor site surgical sites) first tooth, implant, or edentulous tooth position in graft ,067 1,141 1,185 1,236 1, Free soft tissue graft procedure (including recipient and donor site surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site , D4278 D4321 Provisional splinting - extracoronal Periodontal scaling and root planing - four D4341 or more teeth per quadrant Periodontal scaling and root planing - one D4342 to three teeth per quadrant Full mouth debridement to enable D4355 comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into D4381 diseased crevicular tissue, per tooth D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, D5120 Complete denture - mandibular 1, D5130 Immediate denture - maxillary 1, D5140 Immediate denture - mandibular 1, D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 9

12 General Practitioners - National D5212 D5213 D5214 D5221 D5222 D5223 D5224 D5225 Percentile s Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth 1, Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, Immediate maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth 1, Immediate mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth 1, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 10

13 General Practitioners - National Percentile s D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5986 Fluoride gel carrier D5991 Vesiculobullous disease medicament carrier D5994 Periodontal medicament carrier with peripheral seal laboratory processed D6010 Surgical placement of implant body: endosteal implant 1, D6011 Second stage implant surgery D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant 1, D6051 Interim abutment D6055 Connecting bar - implant supported or abutment supported 2, , Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 11

14 General Practitioners - National D6056 D6057 D6059 D6066 D6069 D6076 Percentile s Prefabricated abutment includes modification and placement Custom fabricated abutment - includes placement Abutment supported porcelain fused to metal crown (high noble metal) 1, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1, Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 1, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6100 Implant removal, by report D6104 Bone graft at time of implant placement D6205 Pontic - indirect resin based composite D6210 Pontic - cast high noble metal 1, D6240 Pontic - porcelain fused to high noble metal 1, D6241 Pontic - porcelain fused to predominantly base metal 1, D6245 Pontic - porcelain/ceramic 1, D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression D6545 Retainer - cast metal for resin bonded fixed prosthesis Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 12

15 General Practitioners - National D6549 D6710 D6750 D6751 Percentile s Resin retainer for resin bonded fixed prosthesis Retainer crown - indirect resin based composite Retainer crown - porcelain fused to high noble metal 1, Retainer crown - porcelain fused to predominantly base metal 1, D6790 Retainer crown - full cast high noble metal 1, D6793 Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7251 Coronectomy - intentional partial tooth removal Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 13

16 General Practitioners - National Percentile s D7286 Incisional biopsy of oral tissue - soft D7287 Exfoliative cytological sample collection Brush biopsy transepithelial sample D7288 collection Harvest of bone for use in autogenous D7295 grafting procedure Alveoloplasty in conjunction with extractions - four or more teeth or tooth D7310 spaces, per quadrant Alveoloplasty not in conjunction with extractions - four or more teeth or tooth D7320 spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm Excision of malignant tumor - lesion D7440 diameter up to 1.25 cm Removal of benign odontogenic cyst or D7450 tumor - lesion diameter up to 1.25 cm Mandible - closed reduction (teeth D7640 immobilized, if present) 3, D7880 Occlusal orthotic device, by report D7910 Suture of recent small wounds up to 5 cm D7921 Collection and application of autologous blood concentrate product D7953 Bone replacement graft for ridge preservation per site D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch D8020 Limited orthodontic treatment of the transitional dentition 2, , Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 14

17 General Practitioners - National D8030 D8040 D8050 D8060 D8070 D8080 D8090 Percentile s Limited orthodontic treatment of the adolescent dentition 2, , Limited orthodontic treatment of the adult dentition 2, , Interceptive orthodontic treatment of the primary dentition 2, , Interceptive orthodontic treatment of the transitional dentition 2, , Comprehensive orthodontic treatment of the transitional dentition 5, Comprehensive orthodontic treatment of the adolescent dentition 5, Comprehensive orthodontic treatment of the adult dentition 5, Pre-orthodontic treatment examination to monitor growth and development D8660 D8670 Periodic orthodontic treatment visit Removable orthodontic retainer D8681 adjustment Orthodontic treatment (alternative billing D8690 to a contract fee) D8692 Replacement of lost or broken retainer Palliative (emergency) treatment of dental D9110 pain - minor procedure D9120 Fixed partial denture sectioning Local anesthesia not in conjunction with D9210 operative or surgical procedures Local anesthesia in conjunction with D9215 operative or surgical procedures Inhalation of nitrous oxide/analgesia, D9230 anxiolysis Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 15

18 General Practitioners - National Percentile s Intravenous moderate (conscious) sedation/analgesia - each 15 minute D9243 increment D9248 Non-intravenous conscious sedation Consultation - diagnostic service provided by dentist or physician other than D9310 requesting dentist or physician D9410 House/extended care facility call D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9440 Office visit - after regularly scheduled hours D9450 Case presentation, detailed and extensive treatment planning D9610 Therapeutic parenteral drug, single administration D9630 Other drugs and/or medicaments, by report D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and/or root surface, per tooth D9920 Behavior management, by report D9930 Treatment of complications (postsurgical) unusual circumstances, by report D9932 Cleaning and inspection of removable complete denture, maxillary D9933 Cleaning and inspection of removable complete denture, mandibular Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 16

19 General Practitioners - National D9934 Percentile s Cleaning and inspection of removable partial denture, maxillary Cleaning and inspection of removable partial denture, mandibular D9935 D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9943 Occlusal guard adjustment D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 17

20 General Practitioners - New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0274 Bitewings - four radiographic images D0330 Panoramic radiographic image D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1351 Sealant - per tooth D2140 Amalgam - one surface, primary or permanent Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 18

21 General Practitioners - New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2392 D2393 Percentile s Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle (anterior) Resin-based composite - one surface, posterior Resin-based composite - two surfaces, posterior Resin-based composite - three surfaces, posterior Resin-based composite - four or more surfaces, posterior D2394 D2740 Crown - porcelain/ceramic substrate 1, ,150 1,200 1,350 1,399 1,425 1,473 1,550 1, Crown - porcelain fused to high noble D2750 metal 1, ,104 1,210 1,350 1,420 1,475 1,525 1,550 1, D2752 Crown - porcelain fused to noble metal 1, ,072 1,170 1,281 1,375 1,390 1,420 1,510 1, D2790 Crown - full cast high noble metal 1, ,099 1,223 1,345 1,505 1,550 1,605 1,651 1, Provisional crown further treatment or completion of diagnosis necessary prior to D2799 final impression D2920 Re-cement or re-bond crown Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 19

22 General Practitioners - New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) Percentile s D2940 Protective restoration Core buildup, including any pins when D2950 required Post and core in addition to crown, D2952 indirectly fabricated Prefabricated post and core in addition to D2954 crown Labial veneer (porcelain laminate) - D2962 laboratory 1, ,144 1,300 1,416 1,426 1,510 1,596 1, Pulp cap - direct (excluding final D3110 restoration) Pulp cap - indirect (excluding final D3120 restoration) Therapeutic pulpotomy (excluding final D3220 restoration) Endodontic therapy, anterior tooth D3310 (excluding final restoration) ,050 1, Endodontic therapy, bicuspid tooth D3320 (excluding final restoration) 1, ,125 1,134 1,187 1,200 1, Endodontic therapy, molar (excluding final D3330 restoration) 1, ,076 1,200 1,350 1,375 1,393 1,400 1, Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded D4211 spaces per quadrant Periodontal scaling and root planing - four D4341 or more teeth per quadrant Periodontal scaling and root planing - one D4342 to three teeth per quadrant Full mouth debridement to enable D4355 comprehensive evaluation and diagnosis Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 20

23 General Practitioners - New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) Percentile s Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4381 D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,400 1,588 1,750 2,142 2,150 2,226 2,450 2, D5120 Complete denture - mandibular 1, ,400 1,588 1,750 2,142 2,150 2,226 2,450 2, D5130 Immediate denture - maxillary 1, ,400 1,700 1,828 2,100 2,170 2,322 2,400 2, D5140 Immediate denture - mandibular 1, ,400 1,700 1,850 2,132 2,200 2,322 2,410 2, D5211 D5212 D5213 D5214 D5225 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,000 1,150 1,357 1,766 1,795 1,875 1,950 2, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,048 1,156 1,357 1,733 1,781 1,838 1,950 2, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,495 1,643 1,826 2,150 2,224 2,230 2,459 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,495 1,633 1,826 2,150 2,185 2,237 2,459 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,115 1,300 1,600 1,950 1,970 1,970 2,000 2, D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,170 1,300 1,600 1,946 1,950 1,990 2,000 2, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 21

24 General Practitioners - New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) Percentile s D5650 Add tooth to existing partial denture Add clasp to existing partial denture per D5660 tooth Reline complete maxillary denture D5730 (chairside) Reline complete mandibular denture D5731 (chairside) Reline complete maxillary denture D5750 (laboratory) Reline complete mandibular denture D5751 (laboratory) Prefabricated abutment includes D6056 modification and placement Custom fabricated abutment - includes D6057 placement ,065 1,139 1,200 1, Abutment supported porcelain fused to D6059 metal crown (high noble metal) 1, ,255 1,382 1,520 1,643 1,650 1,700 1,800 2, D6210 Pontic - cast high noble metal 1, ,030 1,160 1,299 1,391 1,420 1,550 1,608 1, Pontic - porcelain fused to high noble D6240 metal 1, ,090 1,185 1,324 1,400 1,420 1,500 1,510 1, D6245 Pontic - porcelain/ceramic 1, ,125 1,200 1,340 1,375 1,395 1,400 1,420 1, Retainer crown - porcelain fused to high D6750 noble metal 1, ,082 1,165 1,291 1,419 1,500 1,525 1,550 1, D6790 Retainer crown - full cast high noble metal 1, ,035 1,113 1,300 1,419 1,500 1,550 1,590 1, D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 22

25 General Practitioners - New England Division (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont) D7210 Percentile s Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Palliative (emergency) treatment of dental pain - minor procedure D9110 D9910 Application of desensitizing medicament D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 23

26 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 24

27 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) Percentile s D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 25

28 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) Percentile s D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Resin-based composite - four or more D2394 surfaces, posterior D2520 Inlay - metallic - two surfaces ,000 1,100 1,189 1,200 1, D2543 Onlay - metallic - three surfaces 1, ,198 1,268 1,350 1,400 1, D2620 Inlay - porcelain/ceramic - two surfaces ,033 1,087 1,200 1,226 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,000 1,200 1,200 1,300 1,325 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,055 1,225 1,353 1,376 1,400 1, D2644 Onlay - porcelain/ceramic - four or more surfaces 1, ,087 1,300 1,365 1,397 1,472 1, D2663 Onlay - resin-based composite - three surfaces ,168 1,194 1,250 1,294 1, D2710 Crown - resin-based composite (indirect) ,195 1,211 1,235 1,250 1, D2740 Crown - porcelain/ceramic substrate 1, ,125 1,317 1,380 1,440 1,500 1, D2750 Crown - porcelain fused to high noble metal 1, ,000 1,102 1,300 1,370 1,410 1,486 1, D2751 Crown - porcelain fused to predominantly base metal 1, ,055 1,240 1,250 1,338 1,350 1, D2752 Crown - porcelain fused to noble metal 1, ,079 1,292 1,300 1,367 1,400 1, D2783 Crown - ¾ porcelain/ceramic 1, ,100 1,250 1,317 1,325 1,382 1, D2790 Crown - full cast high noble metal 1, ,015 1,200 1,350 1,385 1,450 1,500 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 26

29 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) Percentile s Provisional crown further treatment or completion of diagnosis necessary prior to D2799 final impression D2920 Re-cement or re-bond crown Prefabricated stainless steel crown - D2930 primary tooth Prefabricated stainless steel crown - D2931 permanent tooth D2940 Protective restoration Core buildup, including any pins when D2950 required Post and core in addition to crown, D2952 indirectly fabricated Prefabricated post and core in addition to D2954 crown D2961 Labial veneer (resin laminate) - laboratory ,048 1,150 1,205 1,300 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,032 1,275 1,300 1,400 1,472 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement, primary and permanent teeth D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 27

30 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) D3240 D3310 D3320 D3330 Percentile s Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) , Endodontic therapy, bicuspid tooth (excluding final restoration) ,000 1,000 1,056 1,116 1, Endodontic therapy, molar (excluding final restoration) 1, ,000 1,200 1,208 1,275 1,300 1, D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3346 Retreatment of previous root canal therapy anterior ,000 1,050 1,131 1,150 1, D3347 Retreatment of previous root canal therapy bicuspid ,150 1,180 1,200 1,250 1, D3348 Retreatment of previous root canal therapy molar 1, ,150 1,311 1,350 1,350 1,472 1, D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D4240 Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4249 Clinical crown lengthening hard tissue , Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 28

31 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) Percentile s Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant 1, ,005 1,160 1,212 1,250 1,341 1, D4321 Provisional splinting - extracoronal Periodontal scaling and root planing - four D4341 or more teeth per quadrant Periodontal scaling and root planing - one D4342 to three teeth per quadrant Full mouth debridement to enable D4355 comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into D4381 diseased crevicular tissue, per tooth D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,050 1,239 1,513 1,864 1,925 2,000 2,000 2, D5120 Complete denture - mandibular 1, ,050 1,223 1,508 1,899 1,950 2,000 2,000 2, D5130 Immediate denture - maxillary 1, ,170 1,350 1,675 2,000 2,100 2,200 2,351 2, D5140 Immediate denture - mandibular 1, ,170 1,350 1,650 2,000 2,100 2,200 2,375 2, D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,200 1,658 1,722 1,853 2,000 2, D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,210 1,658 1,722 1,853 1,925 2, D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,125 1,320 1,600 1,895 1,900 2,000 2,200 2, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 29

32 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) D5214 D5221 D5222 D5225 Percentile s Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,113 1,335 1,625 1,898 1,902 2,010 2,246 2, Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth 1, ,325 1,800 1,850 1,850 1,900 2, Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,375 1,800 1,850 1,875 1,906 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,195 1,500 1,825 1,900 1,971 2,050 2, D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,195 1,500 1,825 1,900 1,953 2,050 2, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 30

33 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) D5750 Percentile s Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) D5751 D5986 Fluoride gel carrier Prefabricated abutment includes D6056 modification and placement , Custom fabricated abutment - includes D6057 placement ,025 1,125 1,200 1, Abutment supported porcelain fused to D6059 metal crown (high noble metal) 1, ,100 1,267 1,500 1,550 1,620 1,800 1, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high D6066 noble metal) 1, ,060 1,195 1,500 1,800 1,896 1,980 2,000 2, D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,005 1,159 1,350 1,600 1,695 1,825 1,890 1, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal 1, ,100 1,250 1,370 1,400 1,500 1, D6240 Pontic - porcelain fused to high noble metal 1, ,100 1,292 1,395 1,425 1,500 1, D6241 Pontic - porcelain fused to predominantly base metal 1, ,106 1,200 1,250 1,354 1, D6245 Pontic - porcelain/ceramic 1, ,100 1,415 1,440 1,500 1,500 1, D6545 Retainer - cast metal for resin bonded fixed prosthesis ,025 1,100 1, D6750 Retainer crown - porcelain fused to high noble metal 1, ,000 1,138 1,350 1,370 1,410 1,500 1, D6751 Retainer crown - porcelain fused to predominantly base metal 1, ,003 1,218 1,250 1,350 1,365 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 31

34 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) Percentile s D6790 Retainer crown - full cast high noble metal 1, ,132 1,388 1,443 1,500 1,517 1, D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D9110 Palliative (emergency) treatment of dental pain - minor procedure D9120 Fixed partial denture sectioning D9210 Local anesthesia not in conjunction with operative or surgical procedures D9215 Local anesthesia in conjunction with operative or surgical procedures Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 32

35 General Practitioners - Middle Atlantic Division (New Jersey, New York, Pennsylvania) D9230 D9310 D9430 Percentile s Inhalation of nitrous oxide/analgesia, anxiolysis Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit for observation (during regularly scheduled hours) - no other services performed Office visit - after regularly scheduled hours D9440 D9910 Application of desensitizing medicament Application of desensitizing resin for D9911 cervical and/or root surface, per tooth D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 33

36 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 34

37 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) Percentile s D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 35

38 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) Percentile s D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Resin-based composite - four or more D2394 surfaces, posterior D2520 Inlay - metallic - two surfaces ,026 1,070 1,160 1, D2543 Onlay - metallic - three surfaces ,092 1,111 1,163 1,177 1, D2620 Inlay - porcelain/ceramic - two surfaces ,038 1,099 1,128 1,184 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,028 1,120 1,150 1,170 1,200 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,070 1,165 1,196 1,200 1,236 1, D2644 Onlay - porcelain/ceramic - four or more surfaces 1, ,100 1,178 1,200 1,205 1,288 1, D2651 Inlay - resin-based composite -two surfaces ,015 1,032 1,059 1, D2662 Onlay - resin-based composite - two surfaces ,037 1,059 1,120 1,120 1, D2663 Onlay - resin-based composite - three surfaces ,059 1,069 1,119 1,120 1, D2664 Onlay - resin-based composite - four or more surfaces ,069 1,120 1,150 1,196 1, D2710 Crown - resin-based composite (indirect) ,023 1,049 1,091 1,122 1, D2740 Crown - porcelain/ceramic substrate 1, ,092 1,199 1,217 1,262 1,298 1, D2750 Crown - porcelain fused to high noble metal 1, ,067 1,200 1,218 1,264 1,295 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 36

39 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) Percentile s Crown - porcelain fused to predominantly base metal 1, ,000 1,120 1,165 1,189 1,218 1, D2751 D2752 Crown - porcelain fused to noble metal 1, ,030 1,152 1,171 1,200 1,264 1, D2780 Crown - ¾ cast high noble metal 1, ,061 1,181 1,200 1,260 1,301 1, D2783 Crown - ¾ porcelain/ceramic 1, ,100 1,198 1,200 1,220 1,286 1, D2790 Crown - full cast high noble metal 1, ,100 1,204 1,250 1,281 1,350 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2952 Post and core in addition to crown, indirectly fabricated D2954 Prefabricated post and core in addition to crown D2961 Labial veneer (resin laminate) - laboratory ,115 1,165 1,200 1,237 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,100 1,212 1,237 1,295 1,350 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 37

40 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3332 D3346 D3347 D3348 Percentile s Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary and permanent teeth Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) , Endodontic therapy, molar (excluding final restoration) ,089 1,100 1,147 1,171 1, Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior ,005 1, Retreatment of previous root canal therapy bicuspid ,066 1,099 1,100 1,146 1, Retreatment of previous root canal therapy molar 1, ,009 1,142 1,223 1,273 1,316 1,365 1, D3351 Apexification/recalcification - initial visit Apexification/recalcification - interim D3352 medication replacement D3353 Apexification/recalcification final visit Apicoectomy/periradicular surgery - D3410 anterior Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 38

41 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D3421 D4210 D4211 D4212 D4240 Percentile s Apicoectomy/periradicular surgery - bicuspid (first root) , Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4241 D4249 Clinical crown lengthening hard tissue , Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant ,010 1,209 1,217 1,272 1,300 1, D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant ,019 1, D4263 Bone replacement graft - first site in quadrant D4321 Provisional splinting - extracoronal D4341 Periodontal scaling and root planing - four or more teeth per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 39

42 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D4342 D4355 Percentile s Periodontal scaling and root planing - one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4381 D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,180 1,350 1,550 1,800 1,850 1,889 2,013 2, D5120 Complete denture - mandibular 1, ,168 1,350 1,550 1,800 1,850 1,926 2,030 2, D5130 Immediate denture - maxillary 1, ,260 1,445 1,700 1,902 1,974 2,040 2,176 2, D5140 Immediate denture - mandibular 1, ,260 1,450 1,700 1,913 2,000 2,087 2,200 2, D5211 D5212 D5213 D5214 D5225 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,172 1,429 1,505 1,596 1,717 1, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,155 1,423 1,500 1,595 1,717 1, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,210 1,425 1,665 1,855 1,918 2,000 2,125 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,229 1,425 1,669 1,859 1,924 2,000 2,128 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,200 1,470 1,655 1,675 1,750 1,820 1, Mandibular partial denture - flexible base D5226 (including any clasps, rests, and teeth) 1, ,208 1,473 1,639 1,685 1,750 1,835 1, D5510 Repair broken complete denture base Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 40

43 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) Percentile s Replace missing or broken teeth complete denture (each tooth) D5520 D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5986 Fluoride gel carrier D6010 Surgical placement of implant body: endosteal implant 1, ,500 1,565 1,898 2,113 2,200 2,266 2,298 2, D6055 Connecting bar - implant supported or abutment supported 2, , ,500 2,154 2,643 3,184 3,300 3,400 3,967 4, D6056 Prefabricated abutment includes modification and placement D6057 Custom fabricated abutment - includes placement ,001 1,062 1, D6059 Abutment supported porcelain fused to metal crown (high noble metal) 1, ,127 1,281 1,450 1,479 1,540 1,637 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 41

44 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D6066 D6069 D6076 Percentile s Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1, ,063 1,213 1,400 1,592 1,639 1,750 1,850 1, Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,023 1,122 1,298 1,450 1,496 1,565 1,637 1, Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 1, ,050 1,180 1,404 1,613 1,638 1,660 1,835 1, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal 1, ,045 1,175 1,197 1,226 1,287 1, D6240 Pontic - porcelain fused to high noble metal 1, ,069 1,197 1,215 1,250 1,288 1, D6241 Pontic - porcelain fused to predominantly base metal 1, ,008 1,148 1,160 1,191 1,218 1, D6245 Pontic - porcelain/ceramic 1, ,100 1,200 1,205 1,267 1,312 1, D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression , D6545 Retainer - cast metal for resin bonded fixed prosthesis , D6750 Retainer crown - porcelain fused to high noble metal 1, ,074 1,200 1,224 1,264 1,301 1, D6751 Retainer crown - porcelain fused to predominantly base metal 1, ,016 1,157 1,183 1,203 1,261 1, D6790 Retainer crown - full cast high noble metal 1, ,070 1,177 1,207 1,230 1,287 1, D6793 Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 42

45 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D6930 D7111 D7140 Percentile s Re-cement or re-bond fixed partial denture Extraction, coronal remnants -deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7210 D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7288 Brush biopsy transepithelial sample collection D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7880 Occlusal orthotic device, by report ,020 1,072 1,124 1,200 1, D7910 Suture of recent small wounds up to 5 cm Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 43

46 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D7953 Percentile s Bone replacement graft for ridge preservation per site Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7960 D7970 Excision of hyperplastic tissue - per arch Limited orthodontic treatment of the adult D8040 dentition 2, , ,061 2,325 3,066 3,800 3,900 4,000 4,200 4, Comprehensive orthodontic treatment of D8080 the adolescent dentition 5, ,500 4,762 5,097 5,800 5,950 6,127 6,250 6, Comprehensive orthodontic treatment of D8090 the adult dentition 5, ,000 4,680 5,080 5,500 5,705 5,900 6,127 6, D8692 Replacement of lost or broken retainer Palliative (emergency) treatment of dental D9110 pain - minor procedure D9120 Fixed partial denture sectioning Local anesthesia not in conjunction with D9210 operative or surgical procedures Local anesthesia in conjunction with D9215 operative or surgical procedures Inhalation of nitrous oxide/analgesia, D9230 anxiolysis D9248 Non-intravenous conscious sedation Consultation - diagnostic service provided by dentist or physician other than D9310 requesting dentist or physician D9410 House/extended care facility call D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 44

47 General Practitioners - East North Central Division (Illinois, Indiana, Michigan, Ohio, Wisconsin) D9440 D9450 D9610 Percentile s Office visit - after regularly scheduled hours Case presentation, detailed and extensive treatment planning Therapeutic parenteral drug, single administration Other drugs and/or medicaments, by report D9630 D9910 Application of desensitizing medicament Application of desensitizing resin for D9911 cervical and/or root surface, per tooth Treatment of complications (postsurgical) unusual circumstances, by D9930 report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 45

48 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally D0470 Diagnostic casts D1110 Prophylaxis - adult Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 46

49 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) Percentile s D1120 Prophylaxis - child D1206 Topical application of fluoride varnish Topical application of fluoride excluding D1208 varnish Tobacco counseling for the control and D1320 prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth Preventive resin restoration in a moderate to high caries risk patient permanent D1352 tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral Amalgam - one surface, primary or D2140 permanent Amalgam - two surfaces, primary or D2150 permanent Amalgam - three surfaces, primary or D2160 permanent Amalgam - four or more surfaces, primary D2161 or permanent Resin-based composite - one surface, D2330 anterior Resin-based composite - two surfaces, D2331 anterior Resin-based composite - three surfaces, D2332 anterior Resin-based composite - four or more surfaces or involving incisal angle D2335 (anterior) D2390 Resin-based composite crown, anterior Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 47

50 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D2391 D2392 D2393 Percentile s Resin-based composite - one surface, posterior Resin-based composite - two surfaces, posterior Resin-based composite - three surfaces, posterior Resin-based composite - four or more surfaces, posterior D2394 D2520 Inlay - metallic - two surfaces ,004 1,028 1,046 1, D2543 Onlay - metallic - three surfaces ,020 1,068 1,094 1,123 1,154 1, D2620 Inlay - porcelain/ceramic - two surfaces ,029 1,046 1,089 1,130 1, D2642 Onlay - porcelain/ceramic - two surfaces ,020 1,082 1,092 1,108 1,170 1, D2643 Onlay - porcelain/ceramic -three surfaces ,100 1,108 1,143 1,190 1, Onlay - porcelain/ceramic - four or more D2644 surfaces 1, ,020 1,159 1,170 1,180 1,198 1, D2710 Crown - resin-based composite (indirect) ,007 1,011 1,036 1,042 1, D2740 Crown - porcelain/ceramic substrate 1, ,043 1,160 1,190 1,200 1,244 1, D2750 Crown - porcelain fused to high noble metal 1, ,021 1,153 1,190 1,200 1,205 1, D2751 Crown - porcelain fused to predominantly base metal 1, ,003 1,113 1,125 1,160 1,200 1, D2752 Crown - porcelain fused to noble metal 1, ,008 1,150 1,160 1,169 1,200 1, D2780 Crown - ¾ cast high noble metal 1, ,003 1,187 1,194 1,200 1,200 1, D2783 Crown - ¾ porcelain/ceramic 1, ,084 1,180 1,194 1,199 1,200 1, D2790 Crown - full cast high noble metal 1, ,045 1,170 1,199 1,237 1,263 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 48

51 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D2930 Percentile s Prefabricated stainless steel crown - primary tooth Prefabricated stainless steel crown - permanent tooth D2931 D2940 Protective restoration Core buildup, including any pins when D2950 required Post and core in addition to crown, D2952 indirectly fabricated Prefabricated post and core in addition to D2954 crown D2961 Labial veneer (resin laminate) - laboratory ,075 1,088 1,160 1,198 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,035 1,198 1,202 1,245 1,310 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement, primary and permanent teeth D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 49

52 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D3310 D3320 D3330 Percentile s Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) ,065 1,090 1,097 1,140 1, D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3346 Retreatment of previous root canal therapy anterior , D3347 Retreatment of previous root canal therapy bicuspid ,029 1,043 1,100 1,119 1, D3348 Retreatment of previous root canal therapy molar 1, ,075 1,222 1,235 1,275 1,384 1, D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D4240 Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant , D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4249 Clinical crown lengthening hard tissue D4321 Provisional splinting - extracoronal D4341 Periodontal scaling and root planing - four or more teeth per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 50

53 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D4342 D4355 Percentile s Periodontal scaling and root planing - one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4381 D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,200 1,365 1,569 1,760 1,828 1,881 1,900 1, D5120 Complete denture - mandibular 1, ,200 1,373 1,574 1,786 1,829 1,881 1,900 1, D5130 Immediate denture - maxillary 1, ,300 1,494 1,690 1,876 1,930 1,975 2,005 2, D5140 Immediate denture - mandibular 1, ,300 1,494 1,690 1,876 1,930 1,975 2,005 2, D5211 D5212 D5213 D5214 D5225 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,177 1,382 1,417 1,473 1,600 1, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,177 1,391 1,450 1,500 1,600 1, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,335 1,500 1,637 1,835 1,873 1,925 1,965 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,335 1,500 1,639 1,839 1,873 1,925 1,965 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,241 1,444 1,691 1,712 1,750 1,822 1, Mandibular partial denture - flexible base D5226 (including any clasps, rests, and teeth) 1, ,236 1,457 1,696 1,720 1,800 1,887 1, D5510 Repair broken complete denture base Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 51

54 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) Percentile s Replace missing or broken teeth complete denture (each tooth) D5520 D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5986 Fluoride gel carrier D6010 Surgical placement of implant body: endosteal implant 1, ,297 1,675 1,900 2,089 2,170 2,206 2,235 2, D6055 Connecting bar - implant supported or abutment supported 2, , ,289 2,492 2,889 2,979 3,210 3,500 4, D6056 Prefabricated abutment includes modification and placement D6057 Custom fabricated abutment - includes placement , D6059 Abutment supported porcelain fused to metal crown (high noble metal) 1, ,100 1,208 1,403 1,450 1,486 1,500 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 52

55 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D6066 D6069 Percentile s Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1, ,025 1,149 1,347 1,500 1,565 1,630 1,641 1, Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,003 1,187 1,300 1,469 1,489 1,535 1,605 1, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal 1, ,038 1,153 1,181 1,198 1,214 1, D6240 Pontic - porcelain fused to high noble metal 1, ,021 1,135 1,160 1,190 1,205 1, D6241 Pontic - porcelain fused to predominantly base metal ,089 1,119 1,138 1,154 1, D6245 Pontic - porcelain/ceramic 1, ,043 1,165 1,190 1,200 1,212 1, D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression , D6545 Retainer - cast metal for resin bonded fixed prosthesis , D6750 Retainer crown - porcelain fused to high noble metal 1, ,032 1,157 1,187 1,200 1,205 1, D6751 Retainer crown - porcelain fused to predominantly base metal 1, ,117 1,125 1,151 1,198 1, D6790 Retainer crown - full cast high noble metal 1, ,040 1,169 1,195 1,200 1,214 1, D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 53

56 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) Percentile s Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if D7210 indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7880 Occlusal orthotic device, by report ,078 1,144 1,224 1, D7910 Suture of recent small wounds up to 5 cm D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch D8692 Replacement of lost or broken retainer D9110 Palliative (emergency) treatment of dental pain - minor procedure D9120 Fixed partial denture sectioning Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 54

57 General Practitioners - West North Central Division (Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota) D9215 D9230 D9310 Percentile s Local anesthesia in conjunction with operative or surgical procedures Inhalation of nitrous oxide/analgesia, anxiolysis Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9440 Office visit - after regularly scheduled hours D9630 Other drugs and/or medicaments, by report D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and/or root surface, per tooth D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 55

58 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 56

59 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 57

60 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Resin-based composite - four or more D2394 surfaces, posterior D2520 Inlay - metallic - two surfaces ,011 1,120 1,214 1,375 1, D2543 Onlay - metallic - three surfaces 1, ,015 1,155 1,214 1,265 1,450 1, D2620 Inlay - porcelain/ceramic - two surfaces ,076 1,124 1,214 1,250 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,019 1,110 1,137 1,195 1,400 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,060 1,148 1,185 1,200 1,246 1, D2644 Onlay - porcelain/ceramic - four or more surfaces 1, ,110 1,210 1,215 1,246 1,400 1, D2651 Inlay - resin-based composite -two surfaces ,002 1,045 1,120 1,200 1, D2662 Onlay - resin-based composite - two surfaces ,059 1,108 1,145 1,379 1, D2663 Onlay - resin-based composite - three surfaces ,100 1,120 1,200 1,379 1, D2664 Onlay - resin-based composite - four or more surfaces 1, ,124 1,188 1,379 1,407 1, D2710 Crown - resin-based composite (indirect) ,007 1,120 1, D2740 Crown - porcelain/ceramic substrate 1, ,076 1,180 1,268 1,298 1,375 1,407 1, D2750 Crown - porcelain fused to high noble metal 1, ,043 1,125 1,236 1,258 1,298 1,350 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 58

61 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s Crown - porcelain fused to predominantly base metal 1, ,050 1,151 1,185 1,200 1,250 1, D2751 D2752 Crown - porcelain fused to noble metal 1, ,000 1,089 1,198 1,200 1,250 1,325 1, D2780 Crown - ¾ cast high noble metal 1, ,028 1,127 1,250 1,255 1,300 1,468 1, D2783 Crown - ¾ porcelain/ceramic 1, ,000 1,125 1,200 1,280 1,316 1,379 1, D2790 Crown - full cast high noble metal 1, ,098 1,195 1,300 1,336 1,379 1,450 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2952 Post and core in addition to crown, indirectly fabricated D2954 Prefabricated post and core in addition to crown D2961 Labial veneer (resin laminate) - laboratory ,073 1,124 1,160 1,268 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,092 1,184 1,298 1,350 1,400 1,500 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 59

62 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3332 D3346 D3347 D3348 D4210 D4211 Percentile s Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary and permanent teeth Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) ,018 1, Endodontic therapy, molar (excluding final restoration) 1, ,050 1,145 1,181 1,200 1,233 1, Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior ,020 1, Retreatment of previous root canal therapy bicuspid ,033 1,058 1,077 1,100 1, Retreatment of previous root canal therapy molar 1, ,050 1,170 1,241 1,258 1,295 1,300 1, Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 60

63 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) D4212 D4240 Percentile s Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4241 D4249 Clinical crown lengthening hard tissue , Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant 1, ,050 1,200 1,219 1,300 1,400 1, D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant ,000 1,010 1,050 1,090 1, D4263 Bone replacement graft - first site in quadrant D4321 Provisional splinting - extracoronal D4341 Periodontal scaling and root planing - four or more teeth per quadrant D4342 Periodontal scaling and root planing - one to three teeth per quadrant D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,198 1,400 1,635 1,862 1,950 1,996 2,084 2, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 61

64 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s D5120 Complete denture - mandibular 1, ,198 1,400 1,614 1,883 1,950 2,000 2,095 2, D5130 Immediate denture - maxillary 1, ,250 1,500 1,750 1,982 2,000 2,150 2,250 2, D5140 Immediate denture - mandibular 1, ,250 1,500 1,750 1,988 2,095 2,184 2,267 2, D5211 D5212 D5213 D5214 D5225 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,200 1,413 1,450 1,500 1,599 1, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,192 1,410 1,433 1,500 1,595 1, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,250 1,500 1,700 1,900 1,959 2,044 2,150 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,250 1,500 1,700 1,900 1,983 2,044 2,150 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,090 1,227 1,455 1,641 1,675 1,743 1,800 1, D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,250 1,483 1,641 1,675 1,725 1,825 1, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 62

65 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture Reline complete maxillary denture D5730 (chairside) Reline complete mandibular denture D5731 (chairside) Reline complete maxillary denture D5750 (laboratory) Reline complete mandibular denture D5751 (laboratory) D5986 Fluoride gel carrier Surgical placement of implant body: D6010 endosteal implant 1, ,600 1,680 1,904 2,092 2,100 2,109 2,129 2, Connecting bar - implant supported or D6055 abutment supported 2, , ,550 2,700 3,100 3,220 3,301 3,815 5, Prefabricated abutment includes D6056 modification and placement , Custom fabricated abutment - includes D6057 placement ,008 1,100 1, Abutment supported porcelain fused to D6059 metal crown (high noble metal) 1, ,000 1,200 1,366 1,548 1,590 1,601 1,684 1, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high D6066 noble metal) 1, ,038 1,250 1,488 1,699 1,713 1,760 1,820 2, D6069 D6076 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,000 1,200 1,350 1,595 1,600 1,684 1,800 1, Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 1, ,000 1,198 1,398 1,637 1,649 1,700 1,800 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 63

66 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal 1, ,017 1,148 1,268 1,300 1,365 1,500 1, D6240 Pontic - porcelain fused to high noble metal 1, ,000 1,124 1,250 1,289 1,308 1,379 1, D6241 Pontic - porcelain fused to predominantly base metal 1, ,034 1,182 1,199 1,214 1,250 1, D6245 Pontic - porcelain/ceramic 1, ,050 1,157 1,275 1,298 1,360 1,407 1, D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression D6545 Retainer - cast metal for resin bonded fixed prosthesis , D6750 Retainer crown - porcelain fused to high noble metal 1, ,010 1,138 1,214 1,256 1,290 1,302 1, D6751 Retainer crown - porcelain fused to predominantly base metal 1, ,041 1,151 1,175 1,195 1,199 1, D6790 Retainer crown - full cast high noble metal 1, ,017 1,157 1,252 1,300 1,365 1,400 1, D6793 Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 64

67 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if D7210 indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7880 Occlusal orthotic device, by report ,095 1,151 1,176 1,421 1, D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch D8090 Comprehensive orthodontic treatment of the adult dentition 5, ,500 4,971 5,214 5,559 5,750 5,850 6,000 6, D8692 Replacement of lost or broken retainer D9110 Palliative (emergency) treatment of dental pain - minor procedure D9120 Fixed partial denture sectioning Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 65

68 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) D9210 D9215 D9230 Percentile s Local anesthesia not in conjunction with operative or surgical procedures Local anesthesia in conjunction with operative or surgical procedures Inhalation of nitrous oxide/analgesia, anxiolysis Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician D9310 D9410 House/extended care facility call D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9440 Office visit - after regularly scheduled hours D9630 Other drugs and/or medicaments, by report D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and/or root surface, per tooth D9920 Behavior management, by report D9930 Treatment of complications (postsurgical) unusual circumstances, by report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 66

69 General Practitioners - South Atlantic Division (Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., West Virginia) Percentile s D9974 Internal bleaching - per tooth External bleaching for home application, per arch; includes materials and D9975 fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 67

70 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally D0470 Diagnostic casts D1110 Prophylaxis - adult Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 68

71 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) Percentile s D1120 Prophylaxis - child D1206 Topical application of fluoride varnish Topical application of fluoride excluding D1208 varnish Tobacco counseling for the control and D1320 prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral Amalgam - one surface, primary or D2140 permanent Amalgam - two surfaces, primary or D2150 permanent Amalgam - three surfaces, primary or D2160 permanent Amalgam - four or more surfaces, primary D2161 or permanent Resin-based composite - one surface, D2330 anterior Resin-based composite - two surfaces, D2331 anterior Resin-based composite - three surfaces, D2332 anterior Resin-based composite - four or more surfaces or involving incisal angle D2335 (anterior) D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 69

72 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D2393 Percentile s Resin-based composite - three surfaces, posterior Resin-based composite - four or more surfaces, posterior D2394 D2520 Inlay - metallic - two surfaces ,040 1, D2543 Onlay - metallic - three surfaces ,038 1,060 1,148 1,180 1, D2620 Inlay - porcelain/ceramic - two surfaces ,079 1, D2642 Onlay - porcelain/ceramic - two surfaces ,010 1,066 1,099 1, D2643 Onlay - porcelain/ceramic -three surfaces ,030 1,049 1,091 1,100 1, Onlay - porcelain/ceramic - four or more D2644 surfaces ,091 1,097 1,112 1,200 1, D2710 Crown - resin-based composite (indirect) , D2740 Crown - porcelain/ceramic substrate 1, ,020 1,140 1,159 1,238 1,295 1, D2750 Crown - porcelain fused to high noble metal 1, ,107 1,140 1,179 1,238 1, D2751 Crown - porcelain fused to predominantly base metal ,063 1,086 1,100 1,137 1, D2752 Crown - porcelain fused to noble metal ,050 1,086 1,100 1,137 1, D2783 Crown - ¾ porcelain/ceramic ,100 1,105 1,200 1,200 1, D2790 Crown - full cast high noble metal 1, ,075 1,175 1,200 1,238 1,334 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2940 Protective restoration Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 70

73 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D2950 D2952 D2954 Percentile s Core buildup, including any pins when required Post and core in addition to crown, indirectly fabricated Prefabricated post and core in addition to crown D2961 Labial veneer (resin laminate) - laboratory ,010 1,100 1,180 1,200 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,065 1,200 1,250 1,326 1,395 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement, primary and permanent teeth D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) , D3330 Endodontic therapy, molar (excluding final restoration) ,022 1,027 1,039 1,110 1, D3332 D3346 D3347 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior Retreatment of previous root canal therapy bicuspid ,045 1,055 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 71

74 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D3348 D4210 Percentile s Retreatment of previous root canal therapy molar 1, ,025 1,150 1,165 1,240 1,298 1, Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D4211 D4249 Clinical crown lengthening hard tissue D4321 Provisional splinting - extracoronal Periodontal scaling and root planing - four D4341 or more teeth per quadrant Periodontal scaling and root planing - one D4342 to three teeth per quadrant Full mouth debridement to enable D4355 comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into D4381 diseased crevicular tissue, per tooth D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,169 1,402 1,620 1,750 1,800 1,950 2, D5120 Complete denture - mandibular 1, ,138 1,379 1,579 1,749 1,800 1,950 2, D5130 Immediate denture - maxillary 1, ,025 1,203 1,500 1,774 1,850 2,000 2,084 2, D5140 Immediate denture - mandibular 1, ,025 1,225 1,500 1,800 1,850 2,013 2,100 2, D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,270 1,306 1,500 1,550 1, D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,285 1,340 1,500 1,538 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 72

75 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D5213 D5214 D5225 Percentile s Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,097 1,250 1,483 1,650 1,750 1,776 1,800 1, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,097 1,250 1,495 1,650 1,750 1,776 1,800 1, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,214 1,353 1,457 1,625 1,697 1, D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,185 1,355 1,500 1,625 1,697 1, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 73

76 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) Percentile s Reline complete mandibular denture D5751 (laboratory) D5986 Fluoride gel carrier Prefabricated abutment includes D6056 modification and placement Custom fabricated abutment - includes D6057 placement Abutment supported porcelain fused to D6059 metal crown (high noble metal) 1, ,010 1,200 1,332 1,398 1,410 1,499 1, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high D6066 noble metal) 1, ,080 1,278 1,421 1,439 1,489 1,520 1, D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,023 1,193 1,400 1,403 1,417 1,500 1, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal ,099 1,100 1,106 1,203 1, D6240 Pontic - porcelain fused to high noble metal 1, ,100 1,113 1,185 1,230 1, D6241 Pontic - porcelain fused to predominantly base metal ,050 1,091 1,100 1,165 1, D6245 Pontic - porcelain/ceramic 1, ,000 1,141 1,166 1,206 1,276 1, D6545 Retainer - cast metal for resin bonded fixed prosthesis , D6750 Retainer crown - porcelain fused to high noble metal 1, ,100 1,145 1,200 1,238 1, D6751 Retainer crown - porcelain fused to predominantly base metal ,085 1,100 1,115 1,165 1, D6790 Retainer crown - full cast high noble metal 1, ,010 1,125 1,142 1,200 1,200 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 74

77 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D6930 D7111 D7140 Percentile s Re-cement or re-bond fixed partial denture Extraction, coronal remnants -deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7210 D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7880 Occlusal orthotic device, by report ,021 1, D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D9110 Palliative (emergency) treatment of dental pain - minor procedure D9120 Fixed partial denture sectioning Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 75

78 General Practitioners - East South Central Division (Alabama, Kentucky, Mississippi, Tennessee) D9210 D9215 D9230 D9310 D9430 D9440 Percentile s Local anesthesia not in conjunction with operative or surgical procedures Local anesthesia in conjunction with operative or surgical procedures Inhalation of nitrous oxide/analgesia, anxiolysis Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit for observation (during regularly scheduled hours) - no other services performed Office visit - after regularly scheduled hours Other drugs and/or medicaments, by report D9630 D9910 Application of desensitizing medicament Application of desensitizing resin for D9911 cervical and/or root surface, per tooth D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 76

79 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 77

80 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) Percentile s D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 78

81 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) Percentile s D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Resin-based composite - four or more D2394 surfaces, posterior D2520 Inlay - metallic - two surfaces ,159 1,275 1,300 1, D2543 Onlay - metallic - three surfaces 1, ,021 1,152 1,222 1,348 1,409 1, D2620 Inlay - porcelain/ceramic - two surfaces ,042 1,100 1,184 1,340 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,100 1,188 1,234 1,395 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,040 1,127 1,198 1,364 1,400 1, D2644 Onlay - porcelain/ceramic - four or more surfaces 1, ,033 1,166 1,200 1,364 1,495 1, D2662 Onlay - resin-based composite - two surfaces ,177 1,198 1,300 1,308 1, D2710 Crown - resin-based composite (indirect) ,042 1,077 1,177 1,285 1, D2740 Crown - porcelain/ceramic substrate 1, ,078 1,200 1,255 1,302 1,365 1, D2750 Crown - porcelain fused to high noble metal 1, ,073 1,195 1,203 1,300 1,400 1, D2751 Crown - porcelain fused to predominantly base metal 1, ,100 1,146 1,177 1,200 1, D2752 Crown - porcelain fused to noble metal 1, ,010 1,192 1,200 1,245 1,299 1, D2780 Crown - ¾ cast high noble metal 1, ,082 1,195 1,210 1,395 1,450 1, D2783 Crown - ¾ porcelain/ceramic 1, ,082 1,195 1,198 1,205 1,298 1, D2790 Crown - full cast high noble metal 1, ,088 1,200 1,281 1,395 1,400 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 79

82 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) Percentile s Provisional crown further treatment or completion of diagnosis necessary prior to D2799 final impression D2920 Re-cement or re-bond crown Prefabricated stainless steel crown - D2930 primary tooth Prefabricated stainless steel crown - D2931 permanent tooth D2940 Protective restoration Core buildup, including any pins when D2950 required Post and core in addition to crown, D2952 indirectly fabricated Prefabricated post and core in addition to D2954 crown D2961 Labial veneer (resin laminate) - laboratory ,084 1,164 1,200 1,395 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,082 1,200 1,246 1,350 1,395 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement, primary and permanent teeth D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 80

83 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D3240 D3310 D3320 D3330 D3332 D3346 D3347 D3348 Percentile s Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) , Endodontic therapy, molar (excluding final restoration) 1, ,123 1,166 1,200 1,286 1, Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior ,015 1,067 1, Retreatment of previous root canal therapy bicuspid ,035 1,050 1,132 1,180 1, Retreatment of previous root canal therapy molar 1, ,143 1,250 1,298 1,325 1,385 1, D3351 Apexification/recalcification - initial visit Apexification/recalcification - interim D3352 medication replacement D3353 Apexification/recalcification final visit D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) , D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 81

84 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D4211 D4212 D4240 Percentile s Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant , Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4241 D4249 Clinical crown lengthening hard tissue , Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant 1, ,179 1,213 1,300 1,332 1, D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant ,029 1,050 1, D4263 Bone replacement graft - first site in quadrant D4264 Bone replacement graft each additional site in quadrant D4266 Guided tissue regeneration resorbable barrier, per site , D4267 Guided tissue regeneration nonresorbable barrier, per site (includes membrane removal) ,028 1,037 1,188 1, D4321 Provisional splinting - extracoronal Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 82

85 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D4341 D4342 D4355 Percentile s Periodontal scaling and root planing - four or more teeth per quadrant Periodontal scaling and root planing - one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4381 D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,050 1,250 1,500 1,755 1,800 1,900 2,067 2, D5120 Complete denture - mandibular 1, ,050 1,250 1,500 1,748 1,785 1,900 2,088 2, D5130 Immediate denture - maxillary 1, ,124 1,295 1,603 1,876 1,926 2,000 2,182 2, D5140 Immediate denture - mandibular 1, ,124 1,295 1,603 1,876 1,926 1,980 2,182 2, D5211 D5212 D5213 D5214 D5225 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,055 1,300 1,393 1,440 1,545 1, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,064 1,338 1,408 1,492 1,690 1, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,248 1,367 1,592 1,816 1,862 1,925 2,000 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,248 1,367 1,589 1,818 1,862 1,925 2,000 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,100 1,200 1,414 1,550 1,597 1,720 1,851 2, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 83

86 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) Percentile s D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,100 1,200 1,400 1,550 1,597 1,700 1,851 2, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5986 Fluoride gel carrier D6010 Surgical placement of implant body: endosteal implant 1, ,520 1,679 1,810 2,099 2,165 2,244 2,338 2, D6055 Connecting bar - implant supported or abutment supported 2, , ,474 2,344 2,940 3,011 3,320 3,993 4, D6056 Prefabricated abutment includes modification and placement , D6057 Custom fabricated abutment - includes placement , Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 84

87 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D6059 D6066 D6069 D6076 Percentile s Abutment supported porcelain fused to metal crown (high noble metal) 1, ,000 1,200 1,300 1,475 1,488 1,565 1,627 1, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1, ,117 1,200 1,358 1,495 1,525 1,598 1,662 1, Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,006 1,189 1,343 1,451 1,555 1,614 1,650 1, Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 1, ,057 1,200 1,380 1,608 1,662 1,675 1,752 1, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal 1, ,032 1,146 1,195 1,242 1,350 1, D6240 Pontic - porcelain fused to high noble metal 1, ,028 1,136 1,164 1,200 1,340 1, D6241 Pontic - porcelain fused to predominantly base metal 1, ,100 1,124 1,177 1,200 1, D6245 Pontic - porcelain/ceramic 1, ,066 1,203 1,298 1,310 1,400 1, D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression , D6545 Retainer - cast metal for resin bonded fixed prosthesis ,000 1,070 1, D6750 Retainer crown - porcelain fused to high noble metal 1, ,073 1,164 1,195 1,273 1,350 1, D6751 Retainer crown - porcelain fused to predominantly base metal 1, ,005 1,100 1,137 1,198 1,210 1, D6790 Retainer crown - full cast high noble metal 1, ,050 1,177 1,195 1,250 1,355 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 85

88 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D6793 D6930 D7111 D7140 Percentile s Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression Re-cement or re-bond fixed partial denture Extraction, coronal remnants -deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7210 D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7880 Occlusal orthotic device, by report ,000 1,142 1,293 1, D7910 Suture of recent small wounds up to 5 cm Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 86

89 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D7953 Percentile s Bone replacement graft for ridge preservation per site Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7960 D7970 Excision of hyperplastic tissue - per arch Limited orthodontic treatment of the adult D8040 dentition 2, , ,250 1,422 2,550 3,419 3,563 4,200 4,500 4, Comprehensive orthodontic treatment of D8080 the adolescent dentition 4, ,978 4,500 4,928 5,400 5,480 5,500 5,902 6, Comprehensive orthodontic treatment of D8090 the adult dentition 5, ,995 4,545 5,000 5,480 5,500 5,828 6,000 6, D8692 Replacement of lost or broken retainer Palliative (emergency) treatment of dental D9110 pain - minor procedure D9120 Fixed partial denture sectioning Local anesthesia not in conjunction with D9210 operative or surgical procedures Local anesthesia in conjunction with D9215 operative or surgical procedures Inhalation of nitrous oxide/analgesia, D9230 anxiolysis D9248 Non-intravenous conscious sedation Consultation - diagnostic service provided by dentist or physician other than D9310 requesting dentist or physician D9410 House/extended care facility call Office visit for observation (during regularly scheduled hours) - no other D9430 services performed D9440 Office visit - after regularly scheduled hours Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 87

90 General Practitioners - West South Central Division (Arkansas, Louisiana, Oklahoma, Texas) D9610 Percentile s Therapeutic parenteral drug, single administration Other drugs and/or medicaments, by report D9630 D9910 Application of desensitizing medicament Application of desensitizing resin for D9911 cervical and/or root surface, per tooth Treatment of complications (postsurgical) unusual circumstances, by D9930 report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 88

91 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally D0470 Diagnostic casts D1110 Prophylaxis - adult Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 89

92 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) Percentile s D1120 Prophylaxis - child D1206 Topical application of fluoride varnish Topical application of fluoride excluding D1208 varnish Tobacco counseling for the control and D1320 prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral Amalgam - one surface, primary or D2140 permanent Amalgam - two surfaces, primary or D2150 permanent Amalgam - three surfaces, primary or D2160 permanent Amalgam - four or more surfaces, primary D2161 or permanent Resin-based composite - one surface, D2330 anterior Resin-based composite - two surfaces, D2331 anterior Resin-based composite - three surfaces, D2332 anterior Resin-based composite - four or more surfaces or involving incisal angle D2335 (anterior) D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 90

93 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D2393 Percentile s Resin-based composite - three surfaces, posterior Resin-based composite - four or more surfaces, posterior D2394 D2520 Inlay - metallic - two surfaces ,050 1,092 1,120 1, D2543 Onlay - metallic - three surfaces ,149 1,188 1,222 1,303 1, D2620 Inlay - porcelain/ceramic - two surfaces ,051 1,081 1,167 1,246 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,147 1,184 1,280 1,328 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,021 1,145 1,167 1,300 1,350 1, Onlay - porcelain/ceramic - four or more D2644 surfaces 1, ,046 1,223 1,290 1,350 1,359 1, D2710 Crown - resin-based composite (indirect) ,061 1,103 1, D2740 Crown - porcelain/ceramic substrate 1, ,075 1,206 1,245 1,350 1,350 1, D2750 Crown - porcelain fused to high noble metal 1, ,061 1,166 1,244 1,339 1,350 1, D2751 Crown - porcelain fused to predominantly base metal ,050 1,100 1,215 1,238 1, D2752 Crown - porcelain fused to noble metal 1, ,004 1,100 1,236 1,292 1,356 1, D2780 Crown - ¾ cast high noble metal 1, ,103 1,249 1,290 1,350 1,365 1, D2783 Crown - ¾ porcelain/ceramic 1, ,057 1,261 1,290 1,350 1,359 1, D2790 Crown - full cast high noble metal 1, ,087 1,220 1,290 1,339 1,376 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 91

94 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) Percentile s D2940 Protective restoration Core buildup, including any pins when D2950 required Post and core in addition to crown, D2952 indirectly fabricated Prefabricated post and core in addition to D2954 crown D2961 Labial veneer (resin laminate) - laboratory ,042 1,086 1,195 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,060 1,220 1,253 1,376 1,394 1, D2980 Crown repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement, primary and permanent teeth D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) ,000 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 92

95 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D3330 D3346 D3347 D3348 Percentile s Endodontic therapy, molar (excluding final restoration) ,095 1,141 1,149 1,197 1, Retreatment of previous root canal therapy anterior ,025 1, Retreatment of previous root canal therapy bicuspid ,041 1,070 1,108 1,184 1, Retreatment of previous root canal therapy molar 1, ,095 1,229 1,275 1,325 1,339 1, D3351 Apexification/recalcification - initial visit D3352 Apexification/recalcification - interim medication replacement D3410 Apicoectomy/periradicular surgery - anterior D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D4240 Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4249 Clinical crown lengthening hard tissue , D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant ,200 1,209 1,279 1,353 1, D4321 Provisional splinting - extracoronal Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 93

96 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D4341 D4342 D4355 Percentile s Periodontal scaling and root planing - four or more teeth per quadrant Periodontal scaling and root planing - one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4381 D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,140 1,360 1,592 1,795 1,900 2,025 2,136 2, D5120 Complete denture - mandibular 1, ,140 1,360 1,567 1,795 1,900 2,025 2,136 2, D5130 Immediate denture - maxillary 1, ,184 1,400 1,700 1,930 2,050 2,147 2,300 2, D5140 Immediate denture - mandibular 1, ,194 1,392 1,698 1,930 2,050 2,147 2,300 2, D5211 D5212 D5213 D5214 D5225 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,118 1,317 1,393 1,450 1,555 1, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,101 1,325 1,397 1,490 1,548 1, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,200 1,370 1,625 1,895 1,995 2,059 2,200 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,200 1,370 1,625 1,888 1,995 2,059 2,200 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,271 1,464 1,650 1,688 1,760 1,850 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 94

97 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) Percentile s D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,200 1,444 1,650 1,688 1,760 1,850 1, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5986 Fluoride gel carrier D6010 Surgical placement of implant body: endosteal implant 1, ,499 1,561 1,800 1,950 2,060 2,182 2,234 2, D6055 Connecting bar - implant supported or abutment supported 2, , ,061 2,236 3,181 3,471 3,676 3,974 5, D6056 Prefabricated abutment includes modification and placement D6057 Custom fabricated abutment - includes placement ,029 1,090 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 95

98 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D6059 D6066 D6069 Percentile s Abutment supported porcelain fused to metal crown (high noble metal) 1, ,052 1,240 1,400 1,425 1,549 1,765 1, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1, ,100 1,327 1,452 1,545 1,627 1,800 1, Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,159 1,375 1,600 1,647 1,785 1,900 2, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6210 Pontic - cast high noble metal 1, ,028 1,199 1,264 1,303 1,359 1, D6240 Pontic - porcelain fused to high noble metal 1, ,035 1,218 1,266 1,331 1,350 1, D6241 Pontic - porcelain fused to predominantly base metal ,078 1,155 1,188 1,256 1, D6245 Pontic - porcelain/ceramic 1, ,056 1,210 1,238 1,339 1,350 1, D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression , D6545 Retainer - cast metal for resin bonded fixed prosthesis ,000 1,031 1,097 1, D6750 Retainer crown - porcelain fused to high noble metal 1, ,073 1,144 1,223 1,339 1,359 1, D6751 Retainer crown - porcelain fused to predominantly base metal ,100 1,181 1,200 1,290 1, D6790 Retainer crown - full cast high noble metal 1, ,056 1,277 1,305 1,350 1,376 1, D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 96

99 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D7140 Percentile s Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7210 D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch D9110 Palliative (emergency) treatment of dental pain - minor procedure D9120 Fixed partial denture sectioning D9210 Local anesthesia not in conjunction with operative or surgical procedures Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 97

100 General Practitioners - Mountain Division (Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, Wyoming) D9215 D9230 D9310 D9430 D9440 Percentile s Local anesthesia in conjunction with operative or surgical procedures Inhalation of nitrous oxide/analgesia, anxiolysis Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Office visit for observation (during regularly scheduled hours) - no other services performed Office visit - after regularly scheduled hours Other drugs and/or medicaments, by report D9630 D9910 Application of desensitizing medicament Application of desensitizing resin for D9911 cervical and/or root surface, per tooth Treatment of complications (postsurgical) unusual circumstances, by D9930 report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 98

101 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0190 Screening of a patient D0191 Assessment of a patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0251 Extra-oral posterior dental radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 99

102 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) Percentile s Vertical bitewings - 7 to 8 radiographic D0277 images D0330 Panoramic radiographic image D oral/facial photographic image D0350 obtained intra-orally or extra-orally Adjunctive pre-diagnostic test that aids in D0431 detection of mucosal abnormalities D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish D1320 Tobacco counseling for the control and prevention of oral disease D1330 Oral hygiene instructions D1351 Sealant - per tooth D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin-based composite - one surface, anterior Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 100

103 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D2331 D2332 Percentile s Resin-based composite - two surfaces, anterior Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle (anterior) D2335 D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Resin-based composite - four or more D2394 surfaces, posterior D2520 Inlay - metallic - two surfaces ,100 1,150 1, D2543 Onlay - metallic - three surfaces 1, ,120 1,166 1,200 1,261 1, D2620 Inlay - porcelain/ceramic - two surfaces ,127 1,163 1,185 1,240 1, D2642 Onlay - porcelain/ceramic - two surfaces 1, ,018 1,203 1,237 1,250 1,325 1, D2643 Onlay - porcelain/ceramic -three surfaces 1, ,074 1,224 1,249 1,300 1,350 1, D2644 Onlay - porcelain/ceramic - four or more surfaces 1, ,149 1,247 1,300 1,350 1,395 1, D2651 Inlay - resin-based composite -two surfaces ,000 1,069 1,102 1, D2662 Onlay - resin-based composite - two surfaces ,035 1,054 1,156 1,190 1, D2663 Onlay - resin-based composite - three surfaces ,147 1,165 1,195 1,252 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 101

104 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D2664 Percentile s Onlay - resin-based composite - four or more surfaces 1, ,184 1,200 1,258 1,282 1, D2710 Crown - resin-based composite (indirect) ,012 1,076 1,133 1,249 1, D2740 Crown - porcelain/ceramic substrate 1, ,050 1,188 1,315 1,365 1,395 1,431 1, D2750 Crown - porcelain fused to high noble metal 1, ,032 1,150 1,300 1,325 1,369 1,409 1, D2751 Crown - porcelain fused to predominantly base metal 1, ,018 1,200 1,246 1,297 1,323 1, D2752 Crown - porcelain fused to noble metal 1, ,072 1,241 1,290 1,323 1,360 1, D2780 Crown - ¾ cast high noble metal 1, ,115 1,253 1,320 1,343 1,395 1, D2783 Crown - ¾ porcelain/ceramic 1, ,000 1,166 1,332 1,349 1,395 1,431 1, D2790 Crown - full cast high noble metal 1, ,026 1,150 1,326 1,350 1,395 1,421 1, D2794 Crown - titanium 1, ,120 1,309 1,369 1,400 1,453 1, D2799 Provisional crown further treatment or completion of diagnosis necessary prior to final impression D2920 Re-cement or re-bond crown D2929 Prefabricated porcelain/ceramic crown primary tooth D2930 Prefabricated stainless steel crown - primary tooth D2931 Prefabricated stainless steel crown - permanent tooth D2940 Protective restoration D2950 Core buildup, including any pins when required D2952 Post and core in addition to crown, indirectly fabricated D2954 Prefabricated post and core in addition to crown Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 102

105 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) Percentile s D2961 Labial veneer (resin laminate) - laboratory ,150 1,191 1,220 1,300 1, D2962 Labial veneer (porcelain laminate) - laboratory 1, ,000 1,140 1,341 1,392 1,426 1,500 1, D2980 Crown repair necessitated by restorative material failure D2983 Veneer repair necessitated by restorative material failure D3110 Pulp cap - direct (excluding final restoration) D3120 Pulp cap - indirect (excluding final restoration) D3220 Therapeutic pulpotomy (excluding final restoration) D3221 Pulpal debridement, primary and permanent teeth D3222 Partial pulpotomy for apexogenesis permanent tooth with incomplete root development D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) D3310 Endodontic therapy, anterior tooth (excluding final restoration) , D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) ,004 1,050 1,080 1, D3330 Endodontic therapy, molar (excluding final restoration) 1, ,075 1,200 1,248 1,276 1,300 1, D3331 Treatment of root canal obstruction; nonsurgical access Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 103

106 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) Percentile s D3332 D3346 D3347 D3348 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior ,050 1,071 1,100 1, Retreatment of previous root canal therapy bicuspid ,150 1,190 1,208 1,253 1, Retreatment of previous root canal therapy molar 1, ,000 1,193 1,368 1,400 1,444 1,479 1, D3351 Apexification/recalcification - initial visit Apexification/recalcification - interim D3352 medication replacement D3353 Apexification/recalcification final visit D3410 Apicoectomy/periradicular surgery - anterior , D3421 Apicoectomy/periradicular surgery - bicuspid (first root) ,002 1,042 1,085 1, D3425 Apicoectomy/periradicular surgery - molar (first root) ,060 1,092 1,136 1,191 1, D3426 Apicoectomy (each additional root) D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 104

107 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D4240 Percentile s Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant ,079 1, Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant D4241 D4249 Clinical crown lengthening hard tissue ,010 1,045 1, Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant 1, ,070 1,292 1,347 1,450 1,506 1, D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant ,082 1,156 1,174 1,220 1, D4263 Bone replacement graft - first site in quadrant D4264 Bone replacement graft each additional site in quadrant D4266 Guided tissue regeneration resorbable barrier, per site , D4267 Guided tissue regeneration nonresorbable barrier, per site (includes membrane removal) ,030 1,084 1,172 1,202 1, D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position 1, ,000 1,258 1,330 1,361 1,472 1, D4321 Provisional splinting - extracoronal D4341 Periodontal scaling and root planing - four or more teeth per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 105

108 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D4342 D4355 Percentile s Periodontal scaling and root planing - one to three teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D4381 D4910 Periodontal maintenance D5110 Complete denture - maxillary 1, ,254 1,400 1,600 1,936 1,995 2,050 2,168 2, D5120 Complete denture - mandibular 1, ,250 1,409 1,600 1,944 1,995 2,088 2,214 2, D5130 Immediate denture - maxillary 1, ,278 1,472 1,713 1,990 2,022 2,161 2,278 2, D5140 Immediate denture - mandibular 1, ,278 1,456 1,700 1,990 2,025 2,161 2,301 2, D5211 D5212 D5213 D5214 D5221 D5222 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,038 1,339 1,649 1,684 1,802 1,896 2, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,071 1,343 1,629 1,685 1,800 1,891 2, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,300 1,518 1,714 2,000 2,100 2,160 2,255 2, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1, ,300 1,516 1,745 2,002 2,107 2,160 2,255 2, Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth 1, ,000 1,200 1,750 1,803 1,874 1,900 2, Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,200 1,750 1,803 1,838 1,900 2, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 106

109 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D5223 D5224 D5225 Percentile s Immediate maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth 1, ,200 1,300 1,578 1,838 1,874 1,945 2,000 2, Immediate mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth 1, ,200 1,304 1,602 1,856 1,900 1,975 2,000 2, Maxillary partial denture flexible base (including any clasps, rests, and teeth) 1, ,100 1,414 1,786 1,832 1,907 2,027 2, D5226 Mandibular partial denture - flexible base (including any clasps, rests, and teeth) 1, ,100 1,429 1,800 1,838 1,892 2,050 2, D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture per tooth D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5750 Reline complete maxillary denture (laboratory) Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 107

110 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) Percentile s Reline complete mandibular denture D5751 (laboratory) D5986 Fluoride gel carrier Surgical placement of implant body: D6010 endosteal implant 2, ,500 1,849 2,115 2,364 2,400 2,435 2,500 2, Surgical placement of interim implant body for transitional prosthesis: endosteal D6012 implant 1, ,695 2,106 2,253 2,500 2,500 2, D6055 D6056 D6057 D6059 D6066 Connecting bar - implant supported or abutment supported 1, , ,950 3,026 3,128 3,344 3,750 4, Prefabricated abutment includes modification and placement , Custom fabricated abutment - includes placement ,000 1,037 1,110 1,179 1, Abutment supported porcelain fused to metal crown (high noble metal) 1, ,061 1,258 1,500 1,700 1,738 1,800 1,891 2, Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) 1, ,122 1,320 1,519 1,784 1,824 1,936 2,015 2, D6069 D6076 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 1, ,026 1,213 1,460 1,687 1,740 1,802 1,891 2, Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 1, ,037 1,290 1,500 1,700 1,784 1,855 2,140 2, D6080 Implant maintenance procedures when prostheses are removed and reinserted D6205 Pontic - indirect resin based composite ,151 1,160 1,195 1,272 1, D6210 Pontic - cast high noble metal 1, ,096 1,210 1,258 1,320 1,370 1, D6240 Pontic - porcelain fused to high noble metal 1, ,100 1,255 1,291 1,330 1,385 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 108

111 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) Percentile s Pontic - porcelain fused to predominantly D6241 base metal 1, ,132 1,200 1,207 1,298 1, D6245 Pontic - porcelain/ceramic 1, ,108 1,258 1,316 1,351 1,400 1, Provisional pontic - further treatment or completion of diagnosis necessary prior to D6253 final impression D6545 D6750 D6751 Retainer - cast metal for resin bonded fixed prosthesis ,048 1,100 1, Retainer crown - porcelain fused to high noble metal 1, ,012 1,150 1,287 1,302 1,350 1,392 1, Retainer crown - porcelain fused to predominantly base metal 1, ,010 1,187 1,200 1,250 1,300 1, D6790 Retainer crown - full cast high noble metal 1, ,100 1,278 1,301 1,347 1,395 1, D6793 Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression D6930 Re-cement or re-bond fixed partial denture D7111 Extraction, coronal remnants -deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 109

112 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D7240 Percentile s Removal of impacted tooth -completely bony Surgical removal of residual tooth roots (cutting procedure) D7250 D7286 Incisional biopsy of oral tissue - soft Brush biopsy transepithelial sample D7288 collection Alveoloplasty in conjunction with extractions - four or more teeth or tooth D7310 spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm ,000 1, D7880 Occlusal orthotic device, by report ,190 1,317 1,335 1, D7910 Suture of recent small wounds up to 5 cm D7953 Bone replacement graft for ridge preservation per site D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch D8020 Limited orthodontic treatment of the transitional dentition 2, , ,955 2,825 3,334 3,611 3,960 4,000 4, D8030 Limited orthodontic treatment of the adolescent dentition 2, , ,200 2,344 3,034 3,857 4,000 4,200 4,300 4, D8040 Limited orthodontic treatment of the adult dentition 3, , ,005 3,172 4,000 4,200 4,300 4,600 5, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 110

113 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D8050 D8060 D8070 D8080 D8090 Percentile s Interceptive orthodontic treatment of the primary dentition 2, , ,200 2,005 3,085 3,500 3,625 3,960 4,000 4, Interceptive orthodontic treatment of the transitional dentition 2, , ,910 3,000 3,500 3,780 4,000 4,000 4, Comprehensive orthodontic treatment of the transitional dentition 5, ,000 4,990 5,346 6,000 6,000 6,100 6,159 7, Comprehensive orthodontic treatment of the adolescent dentition 5, ,274 4,999 5,500 5,900 5,998 6,000 6,088 6, Comprehensive orthodontic treatment of the adult dentition 5, ,500 5,000 5,525 6,000 6,200 6,399 6,600 6, Pre-orthodontic treatment examination to monitor growth and development D8660 D8692 Replacement of lost or broken retainer Palliative (emergency) treatment of dental D9110 pain - minor procedure D9120 Fixed partial denture sectioning Local anesthesia not in conjunction with D9210 operative or surgical procedures Local anesthesia in conjunction with D9215 operative or surgical procedures Inhalation of nitrous oxide/analgesia, D9230 anxiolysis D9248 Non-intravenous conscious sedation Consultation - diagnostic service provided by dentist or physician other than D9310 requesting dentist or physician D9410 House/extended care facility call Office visit for observation (during regularly scheduled hours) - no other D9430 services performed D9440 Office visit - after regularly scheduled hours Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 111

114 General Practitioners - Pacific Division (Alaska, California, Hawaii, Oregon, Washington) D9450 D9610 Percentile s Case presentation, detailed and extensive treatment planning Therapeutic parenteral drug, single administration Other drugs and/or medicaments, by report D9630 D9910 Application of desensitizing medicament Application of desensitizing resin for D9911 cervical and/or root surface, per tooth Treatment of complications (postsurgical) unusual circumstances, by D9930 report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9972 External bleaching - per arch - performed in office D9974 Internal bleaching - per tooth D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 112

115 Oral and Maxillofacial Surgeons - National D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0330 Panoramic radiographic image D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium D3410 Apicoectomy/periradicular surgery - anterior , D3421 Apicoectomy/periradicular surgery - bicuspid (first root) ,025 1,088 1,100 1, D3425 Apicoectomy/periradicular surgery - molar (first root) ,090 1,100 1,200 1,250 1, D3426 Apicoectomy (each additional root) D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant , D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 113

116 Oral and Maxillofacial Surgeons - National Percentile s D4249 Clinical crown lengthening hard tissue ,033 1,090 1, Bone replacement graft - first site in D4263 quadrant , Guided tissue regeneration resorbable D4266 barrier, per site , Surgical placement of implant body: D6010 endosteal implant 2, ,800 1,948 2,108 2,300 2,369 2,400 2,500 2, Prefabricated abutment includes D6056 modification and placement D6100 Implant removal, by report ,000 1, D6104 Bone graft at time of implant placement Extraction, coronal remnants -deciduous D7111 tooth Extraction, erupted tooth or exposed root D7140 (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if D7210 indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7240 Removal of impacted tooth -completely bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7251 Coronectomy - intentional partial tooth removal D7286 Incisional biopsy of oral tissue - soft Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 114

117 Oral and Maxillofacial Surgeons - National D7310 Percentile s Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7320 D7410 Excision of benign lesion up to 1.25 cm , Excision of malignant tumor - lesion D7440 diameter up to 1.25 cm 1, ,252 1,410 1,600 1,925 2, Removal of benign odontogenic cyst or D7450 tumor - lesion diameter up to 1.25 cm ,000 1,295 1, Mandible - open reduction (teeth D7630 immobilized, if present) 3, , ,500 3,000 3,600 4,750 4,950 5,191 6,500 8, Mandible - closed reduction (teeth D7640 immobilized, if present) 2, , ,550 2,113 2,650 3,500 3,625 3,932 4,718 5, D7730 Mandible - open reduction 4, , ,500 3,269 4,393 5,356 5,616 6,250 7,000 7, D7740 Mandible - closed reduction 3, , ,000 2,400 3,250 4,200 4,300 5,000 5,580 6, D7910 Suture of recent small wounds up to 5 cm , D7953 Bone replacement graft for ridge preservation per site D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch , D9110 Palliative (emergency) treatment of dental pain - minor procedure D9223 Deep sedation/general anesthesia each 15 minute increment D9230 Inhalation of nitrous oxide/analgesia, anxiolysis Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 115

118 Oral and Maxillofacial Surgeons - National Percentile s Intravenous moderate (conscious) sedation/analgesia - each 15 minute D9243 increment D9248 Non-intravenous conscious sedation Consultation - diagnostic service provided by dentist or physician other than D9310 requesting dentist or physician D9440 D9610 Office visit - after regularly scheduled hours Therapeutic parenteral drug, single administration Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 116

119 Endodontists - National Percentile s D0140 Limited oral evaluation - problem focused D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0364 Cone beam CT capture and interpretation with limited field of view less than one whole jaw D2140 Amalgam - one surface, primary or permanent D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) D2391 Resin-based composite - one surface, posterior D2392 Resin-based composite - two surfaces, posterior D2393 Resin-based composite - three surfaces, posterior D2940 Protective restoration D2950 Core buildup, including any pins when required Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 117

120 Endodontists - National D2954 D3110 D3120 D3220 D3221 D3222 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3346 Percentile s Prefabricated post and core in addition to crown Pulp cap - direct (excluding final restoration) Pulp cap - indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary and permanent teeth Partial pulpotomy for apexogenesis permanent tooth with incomplete root development Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) , Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) ,114 1, Endodontic therapy, anterior tooth (excluding final restoration) ,075 1,100 1,150 1,195 1, Endodontic therapy, bicuspid tooth (excluding final restoration) 1, ,058 1,210 1,225 1,250 1,300 1, Endodontic therapy, molar (excluding final restoration) 1, ,015 1,096 1,225 1,375 1,400 1,452 1,525 1, Treatment of root canal obstruction; nonsurgical access Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Retreatment of previous root canal therapy anterior 1, ,065 1,200 1,228 1,275 1,300 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 118

121 Endodontists - National D3347 D3348 Percentile s Retreatment of previous root canal therapy bicuspid 1, ,000 1,075 1,200 1,325 1,370 1,400 1,450 1, Retreatment of previous root canal therapy molar 1, ,150 1,247 1,400 1,525 1,560 1,600 1,650 1, D3351 Apexification/recalcification - initial visit Apexification/recalcification - interim D3352 medication replacement D3353 Apexification/recalcification final visit , D3355 Pulpal regeneration initial visit , D3410 Apicoectomy/periradicular surgery - anterior 1, ,049 1,181 1,237 1,250 1,300 1, D3421 Apicoectomy/periradicular surgery - bicuspid (first root) 1, ,144 1,265 1,300 1,355 1,400 1, D3425 Apicoectomy/periradicular surgery - molar (first root) 1, ,080 1,280 1,415 1,450 1,500 1,595 1, D3426 Apicoectomy (each additional root) D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D9110 Palliative (emergency) treatment of dental pain - minor procedure D9230 Inhalation of nitrous oxide/analgesia, anxiolysis D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 119

122 Endodontists - National Percentile s D9974 Internal bleaching - per tooth Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 120

123 Orthodontists and Dentofacial Orthopedists - National Percentile s Comprehensive oral evaluation new or D0150 established patient D0330 Panoramic radiographic image D oral/facial photographic image D0350 obtained intra-orally or extra-orally D0470 Diagnostic casts D1515 Space maintainer - fixed -bilateral Limited orthodontic treatment of the D8020 transitional dentition 2, , ,060 1,523 2,200 3,200 3,400 3,600 3,995 4, Limited orthodontic treatment of the D8030 adolescent dentition 2, , ,500 2,000 2,786 3,550 3,761 3,980 4,500 5, Limited orthodontic treatment of the adult D8040 dentition 3, , ,000 2,548 3,350 4,024 4,380 4,880 5,030 5, Interceptive orthodontic treatment of the D8050 primary dentition 2, , ,055 1,800 2,390 3,255 3,450 3,761 4,298 4, Interceptive orthodontic treatment of the D8060 transitional dentition 2, ,800 2,200 2,870 3,400 3,500 3,880 4,100 4, Comprehensive orthodontic treatment of D8070 the transitional dentition 5, ,600 4,900 5,400 5,900 5,985 6,075 6,440 6, Comprehensive orthodontic treatment of D8080 the adolescent dentition 5, ,978 5,280 5,610 6,000 6,088 6,350 6,544 6, Comprehensive orthodontic treatment of D8090 the adult dentition 5, ,100 5,500 5,900 6,480 6,500 6,740 6,800 7, D8670 Periodic orthodontic treatment visit Removable orthodontic retainer D8681 adjustment D8692 Replacement of lost or broken retainer Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 121

124 Pediatric Dentists - National D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0273 Bitewings - three radiographic images D0274 Bitewings - four radiographic images D0330 Panoramic radiographic image D0350 2D oral/facial photographic image obtained intra-orally or extra-orally D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1208 Topical application of fluoride excluding varnish Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 122

125 Pediatric Dentists - National Percentile s D1330 Oral hygiene instructions D1351 Sealant - per tooth Preventive resin restoration in a moderate to high caries risk patient permanent D1352 tooth D1510 Space maintainer - fixed -unilateral D1515 Space maintainer - fixed -bilateral Amalgam - one surface, primary or D2140 permanent Amalgam - two surfaces, primary or D2150 permanent Amalgam - three surfaces, primary or D2160 permanent Amalgam - four or more surfaces, primary D2161 or permanent Resin-based composite - one surface, D2330 anterior Resin-based composite - two surfaces, D2331 anterior Resin-based composite - three surfaces, D2332 anterior Resin-based composite - four or more surfaces or involving incisal angle D2335 (anterior) D2390 Resin-based composite crown, anterior Resin-based composite - one surface, D2391 posterior Resin-based composite - two surfaces, D2392 posterior Resin-based composite - three surfaces, D2393 posterior Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 123

126 Pediatric Dentists - National Percentile s Resin-based composite - four or more D2394 surfaces, posterior D2920 Re-cement or re-bond crown Prefabricated porcelain/ceramic crown D2929 primary tooth Prefabricated stainless steel crown - D2930 primary tooth Prefabricated stainless steel crown - D2931 permanent tooth D2940 Protective restoration Core buildup, including any pins when D2950 required Pulp cap - direct (excluding final D3110 restoration) Pulp cap - indirect (excluding final D3120 restoration) Therapeutic pulpotomy (excluding final D3220 restoration) Pulpal debridement, primary and D3221 permanent teeth Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final D3230 restoration) D3240 D3310 D4211 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) ,000 1, Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 124

127 Pediatric Dentists - National D4341 D4355 D7111 D7140 Percentile s Periodontal scaling and root planing - four or more teeth per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Extraction, coronal remnants -deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7210 D7220 Removal of impacted tooth - soft tissue Surgical removal of residual tooth roots D7250 (cutting procedure) D7910 Suture of recent small wounds up to 5 cm D7960 Frenulectomy also known as frenectomy or frenotomy - separate procedure not incidental to another D8050 Interceptive orthodontic treatment of the primary dentition 1, , ,238 2,197 2,303 2,352 2,816 3, D8060 Interceptive orthodontic treatment of the transitional dentition 1, , ,300 2,300 2,597 3,070 3,389 4, D8692 Replacement of lost or broken retainer D9110 Palliative (emergency) treatment of dental pain - minor procedure D9230 Inhalation of nitrous oxide/analgesia, anxiolysis D9248 Non-intravenous conscious sedation Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 125

128 Pediatric Dentists - National D9310 Percentile s Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician D9420 Hospital or ambulatory surgical center call D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9440 Office visit - after regularly scheduled hours D9910 Application of desensitizing medicament D9920 Behavior management, by report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9972 External bleaching - per arch - performed in office D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 126

129 Periodontists - National D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0150 Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) D0171 Re-evaluation post-operative office visit D0180 Comprehensive periodontal evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D0272 Bitewings - two radiographic images D0274 Bitewings - four radiographic images D0277 Vertical bitewings - 7 to 8 radiographic images D0330 Panoramic radiographic image D0470 Diagnostic casts D1110 Prophylaxis - adult D1120 Prophylaxis - child D1206 Topical application of fluoride varnish D1330 Oral hygiene instructions Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 127

130 Periodontists - National D4210 D4211 D4212 D4240 Percentile s Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant ,054 1,200 1,250 1,355 1, Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant , Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth , Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant ,187 1,273 1,400 1,460 1, Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant ,000 1,100 1, D4241 D4249 Clinical crown lengthening hard tissue 1, ,157 1,200 1,230 1,363 1, Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded D4260 spaces per quadrant 1, ,079 1,320 1,600 1,699 1,875 2,000 2, D4261 D4263 D4264 D4266 D4267 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant 1, ,020 1,200 1,250 1,350 1,500 1, Bone replacement graft - first site in quadrant Bone replacement graft each additional site in quadrant Guided tissue regeneration resorbable barrier, per site , Guided tissue regeneration nonresorbable barrier, per site (includes membrane removal) ,045 1,109 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 128

131 Periodontists - National D4273 D4275 D4277 D4278 D4283 Percentile s Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position 1, ,078 1,220 1,416 1,493 1,545 1,600 1, Non-autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft 1, ,040 1,265 1,460 1,500 1,550 1,600 1, Free soft tissue graft procedure (including recipient and donor site surgical sites) first tooth, implant, or edentulous tooth position in graft 1, ,104 1,262 1,300 1,395 1,480 1, Free soft tissue graft procedure (including recipient and donor site surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site ,038 1,150 1,250 1, Autogenous connective tissue graft procedure each additional contiguous tooth, implant or edentulous tooth position in same graft site ,013 1,100 1,229 1,376 1, Non-autogenous connective tissue graft procedure each additional contiguous tooth, implant or edentulous tooth position in same graft site ,000 1,200 1,250 1, D4285 D4321 Provisional splinting - extracoronal Periodontal scaling and root planing - four D4341 or more teeth per quadrant Periodontal scaling and root planing - one D4342 to three teeth per quadrant Full mouth debridement to enable D4355 comprehensive evaluation and diagnosis Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 129

132 Periodontists - National Percentile s Localized delivery of antimicrobial agents via a controlled release vehicle into D4381 diseased crevicular tissue, per tooth D4910 Periodontal maintenance Surgical placement of implant body: D6010 endosteal implant 2, ,850 2,000 2,187 2,350 2,360 2,398 2,500 2, Prefabricated abutment includes D6056 modification and placement , D6100 Implant removal, by report , D6104 Bone graft at time of implant placement , Extraction, erupted tooth or exposed root D7140 (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if D7210 indicated D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth -partially bony D7250 Surgical removal of residual tooth roots (cutting procedure) D7286 Incisional biopsy of oral tissue - soft D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant , D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant ,000 1, D7953 Bone replacement graft for ridge preservation per site ,150 1,200 1, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 130

133 Periodontists - National Percentile s Frenulectomy also known as frenectomy or frenotomy - separate D7960 procedure not incidental to another D7970 Excision of hyperplastic tissue - per arch ,045 1,200 1,280 1,655 1, Palliative (emergency) treatment of dental D9110 pain - minor procedure Inhalation of nitrous oxide/analgesia, D9230 anxiolysis Consultation - diagnostic service provided by dentist or physician other than D9310 requesting dentist or physician D9430 Office visit for observation (during regularly scheduled hours) - no other services performed D9910 Application of desensitizing medicament D9940 Occlusal guard, by report D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 131

134 Prosthodontists - National D0120 Percentile s Periodic oral evaluation established patient D0140 Limited oral evaluation - problem focused D0150 Comprehensive oral evaluation new or established patient D0210 Intraoral - complete series of radiographic images D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image D1110 Prophylaxis - adult D2330 Resin-based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) D2391 Resin-based composite - one surface, posterior D2392 Resin-based composite - two surfaces, posterior D2920 Re-cement or re-bond crown D5110 Complete denture - maxillary 2, ,590 2,000 2,653 3,500 3,504 3,600 3,803 4, D5120 Complete denture - mandibular 2, ,640 2,100 2,675 3,500 3,504 3,600 3,803 4, D5130 Immediate denture - maxillary 2, ,500 1,800 2,314 3,200 3,358 3,500 3,666 3, D5140 Immediate denture - mandibular 2, ,550 1,800 2,332 3,200 3,358 3,500 3,666 3, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 132

135 Prosthodontists - National D5211 D5212 D5213 D5214 Percentile s Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 1, ,029 1,521 2,100 2,266 2,474 3,154 3, Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 1, ,029 1,521 2,221 2,355 2,474 3,154 3, Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 2, ,750 2,121 2,819 3,200 3,200 3,500 3,529 4, Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 2, ,750 2,121 2,819 3,200 3,200 3,500 3,529 4, Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 133

136 Methodology In accordance with a directive from the 1976 House of Delegates, the Health Policy Institute is responsible for periodically gathering and disseminating information regarding dental fees in the United States. The American Dental Association s (ADA) survey of fees charged by general practitioners and specialists is limited to the publication of statistics gathered from a nationwide random sample of dentists, who were asked to record the fee most often charged for each of 271 different dental procedures. The survey data should not be interpreted as constituting a fee schedule in any way, and should not be used for that purpose. Dentists must establish their own fees based on their individual practice and market considerations. The procedure codes on the 2016 Survey of Dental s survey instrument and presented in the tables of this report were taken from CDT 2016, the reference manual published by the ADA. The previous Survey of Dental s used codes based on the 2013 edition of the manual; therefore, care should be taken when comparing data in this report with data from previous ADA Surveys of Dental s or reports from other sources. CDT 2016 contains numerous updates and modifications to procedure codes, descriptors and common dental terms. In this report, data for general practitioners are presented separately for each of the nine U.S. Census Divisions and for the nation as a whole. Following the general practitioner data, national statistics are presented for six dental specialties. The sample design used to select specialists did not provide a sufficient number of specialists to allow for analysis by specialty at the divisional level. Statistics presented for each procedure include the number of respondents, average, standard deviation and percentiles. The Glossary (separate page) includes definitions of these statistics, all of which help indicate how fee answers varied for a given procedure in our survey. To ensure statistical validity, at least 30 responses must have been received for each reported procedure. In both the general practitioner and specialty sections, only those procedures that received 30 or more responses are included in this report. Sampling The 2016 Survey of Dental s sample was selected from the ADA s national sampling frame of active private practitioners ( the population ), which includes member and non-member dentists. The sample, representing 7.4% of the population, was a simple random probability sample of 13,000 dentists in private practice, of whom approximately 60% were general practitioners and 40% were specialists. General practitioners from the New England and East South Central divisions were also oversampled to ensure a sufficient number of responses. Representativeness was determined by checking for statistically significant differences between the sample and population on the following demographic characteristics using chi-square statistics and T-tests: division, primary occupation, secondary occupation, specialty, race, ownership status, age, and graduation year. No statistically significant differences were found between any of the subsamples of general practitioners and specialists and their populations. Data collection The 2016 Survey of Dental s was initially mailed to 13,000 dentists in private practice in March 2016, and two follow-up mailings to nonrespondents were sent in May and July. Data collection was concluded in August 2016 after responses had been received from 1,695 dentists. The final adjusted response rate of 13.8% excludes those individuals who were retired, not in private practice, deceased, or had unknown or foreign addresses. Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 134

137 Weighting The proportion of oversampled dentists in the sample and among the respondents was higher than in the actual population. To be able to make statements about all private practitioners, all general practitioners, or all specialists, the proportion of general practitioners and specialists among the respondents had to match those of the sample frame and the dental population as a whole. If left unbalanced, the statistics presented for all dentists, all general practitioners, or all specialists would have been skewed by the disproportionate number of oversampled dentists among the respondents and would not have been an accurate representation of the dental population being analyzed In the sampling frame, 3.8% of dentists were New England general practitioners, 3.8% were East South Central general practitioners, 52.3% were general practitioners from other divisions, and 40.0% were specialists. Among the respondents to the survey, 5.0% of dentists were New England general practitioners, 8.0% were East South Central general practitioners, 49.0% were general practitioners from other divisions, and 38.0% were specialists. Weights were calculated for these five sets of dentists to bring the proportions found among the respondents into line with those found in the dental population. In this report, the weights were used in the calculation of statistics in which all general practitioners were combined. Weights were not used when a single division of general practitioners or a single specialty were analyzed separately. Statistics computed with weights are indicated as such in the report. Each weight was calculated by dividing the percentage of each in the sampling frame by the percentage in the respondent population Percentage in the sampling frame Percentage in the respondent population = Weight Weighting scheme for reporting all general practitioners combined General practitioners General practitioners = (New England) (East South Central) = General practitioners General practitioners = (Middle Atlantic) (West South Central) = General practitioners General practitioners = (East North Central) (Mountain) = General practitioners General practitioners = (West North Central) (Pacific) = General practitioners (South Atlantic) = For example, when reporting all general practitioners combined, weighting had the effect of turning every responding general practitioner from the New England division into general practitioners. Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 135

138 Glossary AVERAGE The arithmetic average of all fees reported by the respondents, obtained by taking the sum of all fees and dividing by the number of responses. It is possible that no dentist reported charging a fee that is exactly equal to the average value. If the distribution of fees is not symmetrical (that is, one half is not the mirror image of the other), the median is a better indicator of the typical fee charged than the average. CHI-SQUARE STATISTICS Chi-square statistics indicate, in the context of this report, whether the demographic characteristics of a random sample occur with a distribution similar to that of the population from which the sample is drawn. DIVISIONS Nine U.S. Census Divisions: New England: Middle Atlantic: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. New Jersey, New York, and Pennsylvania. East North Central: Illinois, Indiana, Michigan, Ohio, and Wisconsin. West North Central: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and South Dakota. South Atlantic: Delaware, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, Washington D.C., and West Virginia. East South Central: Alabama, Kentucky, Mississippi, and Tennessee. West South Central: Arkansas, Louisiana, Oklahoma, and Texas. Mountain: Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Utah, and Wyoming. Pacific: Alaska, California, Hawaii, Oregon, and Washington. Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 136

139 MEDIAN A statistical measure that divides ranked numeric responses into halves. The median is the response that falls at the fifty percent mark. The responses in one half are all smaller than the median and those in the other half are all larger than the median. PERCENTILE A percentile represents a fee at which a certain percentage of dentists charge up to the value of that fee. Example: the percentile describes the fee equal to or greater than 75% of the fees for a given procedure. SIMPLE RANDOM PROBABILITY SAMPLE STANDARD DEVIATION (S.D.) A simple random probability sample denotes a sample in which names are drawn at random without replacement. The typical deviation of sample values from the mean. The size of the standard deviation reflects the accuracy of the sample mean in representing the population. In a normal population, 68.0% of the observations fall within one standard deviation of the mean, 95.5% within two standard deviations, and 99.7% within three standard deviations. T-TESTS T-tests indicate, in the context of this report, whether the mean values of numeric demographic characteristics (age, year of graduation) of a random sample are statistically similar to those of the population from which the sample is drawn. Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 137

140 211 East Chicago Avenue Health Policy Institute Chicago, Illinois Survey of Dental s Please circle the number corresponding to the most appropriate response or fill in the blank. Please do not report ranges. 1. What is your current occupation? (Please circle only one response). a. Private practice (full- or part-time)... 1 b. Other dental occupation... 2 c. Other non-dental occupation... 3 Please complete this questionnaire if you are currently in private practice. Otherwise, stop here and return the questionnaire. Thank you. 2. In your primary practice in 2016, in which of the following ADA-recognized specialty areas were you announcing yourself and practicing as a licensed specialist? (Circle one response). a. No specialty. I am a general practitioner... 0 b. Oral and maxillofacial surgery... 1 c. Endodontics... 2 d. Orthodontics and dentofacial orthopedics... 3 e. Pediatric dentistry... 4 f. Periodontics... 5 g. Prosthodontics... 6 h. Oral and maxillofacial pathology... 7 i. Public health... 8 j. Oral and maxillofacial radiology Please describe your primary practice. You are: a. A sole practitioner... 1 b. In a practice with 2 to 5 dentists... 2 c. In a practice with 6 to 10 dentists... 3 d. In a practice with 11 to 20 dentists... 3 e. In a practice with 21 to 100 dentists... 4 f. In a practice with more than 100 dentists What is the zip code of your primary practice?... SAMPLE zip code 5. Approximately what percentage of the patients who currently visit the entire primary practice are: a. Covered by a private benefit program that pays or partially pays for their dental care?... % b. Covered by a public assistance program that pays or partially pays for their dental care?... % c. Not covered by an insurance program?... Total 100% % 6. Please indicate the number of participating provider contracts you have with the following: a. PPO plans... b. DHMO plans.... c. Discount plans In your opinion, how much are your fees discounted by managed care plans on an average percentage basis? a. <10%... 1 b %... 2 c %... 3 d. >40% Do you or does your practice management system submit your full fee and all claim submissions to payers? Yes... 1 No How frequently do you update your fees? (Select the closest time interval). a. Less than 6 months between updates... 1 b. Every 6 months... 2 c. Every year... 3 d. Every two years... 4 e. More than two years between updates... 5 PLEASE READ THESE IMPORTANT INSTRUCTIONS BEFORE CONTINUING: For the following procedures, record your full fee not the portion that you expect to receive or for which you might be reimbursed. A full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist s professional judgment. A contractual relationship does not change the dentist s full fee. It is always appropriate to report the full fee for each service reported to a third-party payer. Do not report a fee range. Record a single fee for each service. If you provide certain services without charge, write 0 (zero). If you do not perform a certain procedure, leave the corresponding space blank. codes from the most recent revision of the ADA's on Dental s and Nomenclature are provided for your assistance in specifying services. All codes and nomenclature are published in the ADA's CDT 2016: Dental s. Legal Disclaimer: This survey is taken in accordance with Statement 6 of the Federal Trade Commission s Statements of Antitrust Enforcement Policy in HealthCare. Dentists are reminded to avoid sharing fee or cost information with their competitors. Source: American Dental Association, Health Policy Institute, 2016 Survey of Dental s. Copyright 2016 American Dental Association. 138