AmeriPlan Lime Fee Zip: 78411 SPECIALIST FEE SCHEDULE Any AmeriPlan /Dental Plans of America member receiving treatment from a participating specialist provider (advanced degree), shall receive a 15% discount off the participating specialist's usual and customary fee for that procedure. These participating specialists include the following: Orthodontists Periodontists Endodontists Prosthodontists Pedodontists Oral Surgeons ADA Code Dentist Procedures AmeriPlan Fees 00120 Periodic Oral Exam $15 00120 Periodic Oral Exam $15 00120 Periodic Oral Exam $15 00140 Limited Oral Exam $22 00140 Limited Oral Exam $22 00140 Limited Oral Exam $22 00150 Initial Oral Exam $49 00150 Initial Oral Exam $49 00150 Initial Oral Exam $49 00180 Comprehensive Periodontal Evaluation 00180 Comprehensive Periodontal Evaluation 00180 Comprehensive Periodontal Evaluation 00210 X-Ray: Intraoral Complete Series $80 00210 X-Ray: Intraoral Complete Series $80 00210 X-Ray: Intraoral Complete Series $80 00220 Intraoral - Periapical - First film $20 00220 Intraoral - Periapical - First film $20 00220 Intraoral - Periapical - First film $20 00230 Intraoral - Periapical - each additional film $15 00230 Intraoral - Periapical - each additional film $15 00230 Intraoral - Periapical - each additional film $15 00240 Intraoral - Occlusal film $25 00240 Intraoral - Occlusal film $25
00240 Intraoral - Occlusal film $25 00250 Extraoral - first film 00250 Extraoral - first film 00250 Extraoral - first film 00260 Extraoral - each additional film 00260 Extraoral - each additional film 00260 Extraoral - each additional film 00270 Bitewing - Single film $23 00270 Bitewing - Single film $23 00270 Bitewing - Single film $23 00272 Bitewings - 2 films $30 00272 Bitewings - 2 films $30 00272 Bitewings - 2 films $30 00273 Bitewings - 3 films 00273 Bitewings - 3 films 00273 Bitewings - 3 films 00274 Bitewings - 4 films $40 00274 Bitewings - 4 films $40 00274 Bitewings - 4 films $40 00330 X-Ray: Panoramic $75 00330 X-Ray: Panoramic $75 00330 X-Ray: Panoramic $75 00340 Cephalometric film 00340 Cephalometric film 00340 Cephalometric film 00460 Pulp Vitality Test 00460 Pulp Vitality Test 00460 Pulp Vitality Test 00470 Diagnostic Casts 00470 Diagnostic Casts 00470 Diagnostic Casts 00471 Diagnostic photographs 00471 Diagnostic photographs 00471 Diagnostic photographs
00999 00999 00999 01110 01110 01110 01120 01120 01120 01201 01201 01201 01203 01203 01203 01204 01204 01204 Infection Control - OSHA requirements to prevent transmission of disease Infection Control - OSHA requirements to prevent transmission of disease Infection Control - OSHA requirements to prevent transmission of disease Regular Teeth Cleaning (Light Scaling & Polishing) Regular Teeth Cleaning (Light Scaling & Polishing) Regular Teeth Cleaning (Light Scaling & Polishing) Prophylaxis - Child (to include light scaling and polishing) Prophylaxis - Child (to include light scaling and polishing) Prophylaxis - Child (to include light scaling and polishing) Topical Application of Fluoride (including prophylaxis - child) Topical Application of Fluoride (including prophylaxis - child) Topical Application of Fluoride (including prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - adult) Topical Application of Fluoride (excluding prophylaxis - adult) Topical Application of Fluoride (excluding prophylaxis - adult) $50 $50 $50 $42 $42 $42 $47 $47 $47 $18 $18 $18 $18 $18 $18 01205 Regular Teeth Cleaning (with Fluoride) $55 01205 Regular Teeth Cleaning (with Fluoride) $55 01205 Regular Teeth Cleaning (with Fluoride) $55
01208 Topical Application of Fluoride $18 01208 Topical Application of Fluoride $18 01208 Topical Application of Fluoride $18 01330 Oral Hygiene Instruction $19 01330 Oral Hygiene Instruction $19 01330 Oral Hygiene Instruction $19 01351 Sealant - per tooth $25 01351 Sealant - per tooth $25 01351 Sealant - per tooth $25 01510 Space Maintainer - fixed unilateral type 01510 Space Maintainer - fixed unilateral type 01510 Space Maintainer - fixed unilateral type 01515 Space Maintainer - fixed bilateral type 01515 Space Maintainer - fixed bilateral type 01515 Space Maintainer - fixed bilateral type 01520 Space maintainer - removable unilateral type 01520 Space maintainer - removable unilateral type 01520 Space maintainer - removable unilateral type 01525 Space maintainer - removable bilateral type 01525 Space maintainer - removable bilateral type 01525 Space maintainer - removable bilateral type 01550 Re-cementation of space maintainer 01550 Re-cementation of space maintainer 01550 Re-cementation of space maintainer 02140 02140 02140 02150 02150 Amalgam Filling (Silver Colored) 1 Surface (Anterior) Amalgam Filling (Silver Colored) 1 Surface (Anterior) Amalgam Filling (Silver Colored) 1 Surface (Anterior) Amalgam Filling (Silver Colored) 2 Surface (Anterior) Amalgam Filling (Silver Colored) 2 Surface (Anterior) 02150 Amalgam Filling (Silver Colored) 2 Surface
02160 02160 02160 02161 02161 02161 (Anterior) Amalgam - 3 surfaces, primary or permanent, per tooth Amalgam - 3 surfaces, primary or permanent, per tooth Amalgam - 3 surfaces, primary or permanent, per tooth Amalgam - 4 or more surfaces, primary or permanent, per tooth Amalgam - 4 or more surfaces, primary or permanent, per tooth Amalgam - 4 or more surfaces, primary or permanent, per tooth 02330 Resin Based composite - 1 Surface, Anterior 02330 Resin Based composite - 1 Surface, Anterior 02330 Resin Based composite - 1 Surface, Anterior 02331 Resin Based Composite - 2 Surface Anterior 02331 Resin Based Composite - 2 Surface Anterior 02331 Resin Based Composite - 2 Surface Anterior 02332 Resin based composite - 3 surface, anterior 02332 Resin based composite - 3 surface, anterior 02332 Resin based composite - 3 surface, anterior 02335 02335 02335 Resin based composite - 4 surfaces or more involving incisal angle, anterior Resin based composite - 4 surfaces or more involving incisal angle, anterior Resin based composite - 4 surfaces or more involving incisal angle, anterior 02391 Resin based composite - 1 surface, posterior 02391 Resin based composite - 1 surface, posterior 02391 Resin based composite - 1 surface, posterior 02392 Resin based composite - 2 surface, posterior 02392 Resin based composite - 2 surface, posterior 02392 Resin based composite - 2 surface, posterior 02393 Resin based composite - 3 surface, posterior 02393 Resin based composite - 3 surface, posterior
02393 Resin based composite - 3 surface, posterior 02394 02394 02394 Resin based composite - 4 surfaces or more, posterior Resin based composite - 4 surfaces or more, posterior Resin based composite - 4 surfaces or more, posterior 02510 Inlay - 1 surface, Metallic 02510 Inlay - 1 surface, Metallic 02510 Inlay - 1 surface, Metallic 02520 Inlay - 2 surfaces, Metallic 02520 Inlay - 2 surfaces, Metallic 02520 Inlay - 2 surfaces, Metallic 02530 Inlay - 3 surfaces, Metallic 02530 Inlay - 3 surfaces, Metallic 02530 Inlay - 3 surfaces, Metallic 02540 02540 02540 Onlay - metallic, per tooth (in addition to inlay) Onlay - metallic, per tooth (in addition to inlay) Onlay - metallic, per tooth (in addition to inlay) 02542 Onlay - metallic - 2 surface 02542 Onlay - metallic - 2 surface 02542 Onlay - metallic - 2 surface 02710 Crown - Resin based composite (indirect) 02710 Crown - Resin based composite (indirect) 02710 Crown - Resin based composite (indirect) 02740 Crown - Porcelain/Ceramic Substrate 02740 Crown - Porcelain/Ceramic Substrate 02740 Crown - Porcelain/Ceramic Substrate 02750 Porcelain Crown with High Noble Metal 02750 Porcelain Crown with High Noble Metal 02750 Porcelain Crown with High Noble Metal 02751 Crown - Porcelain fused to predcominantly base metal
02751 02751 Crown - Porcelain fused to predcominantly base metal Crown - Porcelain fused to predcominantly base metal 02752 Crown - Porcelain fused to noble metal 02752 Crown - Porcelain fused to noble metal 02752 Crown - Porcelain fused to noble metal 02790 Crown - Full cast high noble metal 02790 Crown - Full cast high noble metal 02790 Crown - Full cast high noble metal 02791 Crown - Full cast predominantly base metal 02791 Crown - Full cast predominantly base metal 02791 Crown - Full cast predominantly base metal 02792 Crown - Full cast noble metal 02792 Crown - Full cast noble metal 02792 Crown - Full cast noble metal 02810 Crown - 3/4 cast metallic 02810 Crown - 3/4 cast metallic 02810 Crown - 3/4 cast metallic 02910 Recement Inlay 02910 Recement Inlay 02910 Recement Inlay 02920 Recement Crown 02920 Recement Crown 02920 Recement Crown 02930 02930 02930 02931 02931 Prefabricated Stainless Steel Crown, primary tooth Prefabricated Stainless Steel Crown, primary tooth Prefabricated Stainless Steel Crown, primary tooth Prefabricated Stainless Steel Crown, permanent tooth Prefabricated Stainless Steel Crown, permanent tooth 02931 Prefabricated Stainless Steel Crown,
permanent tooth 02932 Prefabricated Resin Crown 02932 Prefabricated Resin Crown 02932 Prefabricated Resin Crown 02940 Sedative Filling 02940 Sedative Filling 02940 Sedative Filling 02950 Crown build up, including any pins 02950 Crown build up, including any pins 02950 Crown build up, including any pins 02951 02951 02951 Pin retention per tooth in addition to restoration Pin retention per tooth in addition to restoration Pin retention per tooth in addition to restoration 02952 Cast post and core in addition to crown 02952 Cast post and core in addition to crown 02952 Cast post and core in addition to crown 02953 Cast post as part of crown 02953 Cast post as part of crown 02953 Cast post as part of crown 02954 02954 02954 Prefabricated post and core in addition to crown Prefabricated post and core in addition to crown Prefabricated post and core in addition to crown 02960 Labial veneer (laminate) chairside 02960 Labial veneer (laminate) chairside 02960 Labial veneer (laminate) chairside 02962 Labial veneer (porcelain laminate) laboratory 02962 Labial veneer (porcelain laminate) laboratory 02962 Labial veneer (porcelain laminate) laboratory 02970 Temporary Crown (artificial over damaged tooth)
02970 02970 Temporary Crown (artificial over damaged tooth) Temporary Crown (artificial over damaged tooth) 02980 Crown repair, by report 02980 Crown repair, by report 02980 Crown repair, by report 02999 Cosmetic, bonding, bleaching and veneers 02999 Cosmetic, bonding, bleaching and veneers 02999 Cosmetic, bonding, bleaching and veneers 03110 Pulp Cap - Direct (excluding final restoration) 03110 Pulp Cap - Direct (excluding final restoration) 03110 Pulp Cap - Direct (excluding final restoration) 03120 03120 03120 03220 03220 03220 Pulp Cap - Indirect (excluding final restoration) Pulp Cap - Indirect (excluding final restoration) Pulp Cap - Indirect (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) 03310 Root Canal Anterior 03310 Root Canal Anterior 03310 Root Canal Anterior 03320 Root Canal Bicuspid 03320 Root Canal Bicuspid 03320 Root Canal Bicuspid 03330 03330 03330 Root Canal - Molar (excluding final restoration) Root Canal - Molar (excluding final restoration) Root Canal - Molar (excluding final restoration)
03346 Retreatment of prev. root canal, anterior 03346 Retreatment of prev. root canal, anterior 03346 Retreatment of prev. root canal, anterior 03347 Retreatment of prev. root canal, bicuspid 03347 Retreatment of prev. root canal, bicuspid 03347 Retreatment of prev. root canal, bicuspid 03348 Retreatment of prev. root canal, molar 03348 Retreatment of prev. root canal, molar 03348 Retreatment of prev. root canal, molar 03410 Apicoectomy - anterior 03410 Apicoectomy - anterior 03410 Apicoectomy - anterior 03421 Apicoectomy - bicuspid (first root) 03421 Apicoectomy - bicuspid (first root) 03421 Apicoectomy - bicuspid (first root) 03425 Apicoectomy - molar (first root) 03425 Apicoectomy - molar (first root) 03425 Apicoectomy - molar (first root) 03450 Root amputation (per root) 03450 Root amputation (per root) 03450 Root amputation (per root) 03460 Endodontic endosseous implant 03460 Endodontic endosseous implant 03460 Endodontic endosseous implant 03470 03470 03470 03920 03920 Intentional reimplantation (including necessary splinting) Intentional reimplantation (including necessary splinting) Intentional reimplantation (including necessary splinting) Hemisection (including any root removal) not including root canal therapy Hemisection (including any root removal) not including root canal therapy 03920 Hemisection (including any root removal) not
including root canal therapy 03960 Bleaching of discolored tooth 03960 Bleaching of discolored tooth 03960 Bleaching of discolored tooth 03999 Unspecified endodontic procedure 03999 Unspecified endodontic procedure 03999 Unspecified endodontic procedure 04210 Gingivectomy or gingivoplasty - per quadrant 04210 Gingivectomy or gingivoplasty - per quadrant 04210 Gingivectomy or gingivoplasty - per quadrant 04211 Gingivectomy or gingivoplasty - per tooth 04211 Gingivectomy or gingivoplasty - per tooth 04211 Gingivectomy or gingivoplasty - per tooth 04240 04240 04240 Gingival Flap Procedure, including root planing Gingival Flap Procedure, including root planing Gingival Flap Procedure, including root planing 04249 Clinical crown lengthening - hard tissue 04249 Clinical crown lengthening - hard tissue 04249 Clinical crown lengthening - hard tissue 04250 Mucogingival surgery - per quadrant 04250 Mucogingival surgery - per quadrant 04250 Mucogingival surgery - per quadrant 04260 04260 04260 Osseous Surgery (including flap entry and closure) Osseous Surgery (including flap entry and closure) Osseous Surgery (including flap entry and closure) 04263 Bone replacement graft - first site in quadrant 04263 Bone replacement graft - first site in quadrant 04263 Bone replacement graft - first site in quadrant 04264 Bone replacement graft - each additional site in quadrant
04264 04264 04266 04266 04266 04267 04267 04267 Bone replacement graft - each additional site in quadrant Bone replacement graft - each additional site in quadrant Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - nonresorbable barrier Guided tissue regeneration - nonresorbable barrier Guided tissue regeneration - nonresorbable barrier 04270 Pedicle Soft Tissue Graft Procedure 04270 Pedicle Soft Tissue Graft Procedure 04270 Pedicle Soft Tissue Graft Procedure 04271 Free Soft Tissue Graft Procedure 04271 Free Soft Tissue Graft Procedure 04271 Free Soft Tissue Graft Procedure 04273 04273 04273 Subepithelial connective tissue graft procedure per tooth Subepithelial connective tissue graft procedure per tooth Subepithelial connective tissue graft procedure per tooth 04274 Distal or proximal wedge procedure 04274 Distal or proximal wedge procedure 04274 Distal or proximal wedge procedure 04320 Provisional splinting - intracoronal 04320 Provisional splinting - intracoronal 04320 Provisional splinting - intracoronal 04321 Provisional splinting - extracoronal 04321 Provisional splinting - extracoronal 04321 Provisional splinting - extracoronal
04341 04341 04341 04355 04355 04355 04381 04381 04381 04910 04910 04910 Periodontial Scaling and Root Planing - per quadrant Periodontial Scaling and Root Planing - per quadrant Periodontial Scaling and Root Planing - per quadrant Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup) Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup) Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup) Localized delivery of chemotherapeutic agents via controlled release Localized delivery of chemotherapeutic agents via controlled release Localized delivery of chemotherapeutic agents via controlled release Periodontal maintenance procedures following active therapy Periodontal maintenance procedures following active therapy Periodontal maintenance procedures following active therapy 04999 Unspecified periodontic procedure 04999 Unspecified periodontic procedure 04999 Unspecified periodontic procedure 05110 Complete Upper Denture 05110 Complete Upper Denture 05110 Complete Upper Denture 05120 Complete Lower Denture 05120 Complete Lower Denture 05120 Complete Lower Denture 05130 Immediate Upper Denture 05130 Immediate Upper Denture
05130 Immediate Upper Denture 05140 Immediate Lower Denture 05140 Immediate Lower Denture 05140 Immediate Lower Denture 05211 05211 05211 05212 05212 05212 05213 05213 05213 05214 05214 05214 05281 05281 Upper Partial - acrylic base (including any conventional clasps, rests and teeth) Upper Partial - acrylic base (including any conventional clasps, rests and teeth) Upper Partial - acrylic base (including any conventional clasps, rests and teeth) Lower Partial - acrylic base (including any conventional clasps, rests and teeth) Lower Partial - acrylic base (including any conventional clasps, rests and teeth) Lower Partial - acrylic base (including any conventional clasps, rests and teeth) Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps, rests and teeth) Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps, rests and teeth) Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps, rests and teeth) Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps, rest and teeth) Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps, rest and teeth) Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps, rest and teeth) Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Removable unilateral partial denture - one piece cast metal (including clasps and teeth) 05281 Removable unilateral partial denture - one
piece cast metal (including clasps and teeth) 05410 Adjust Complete Denture - upper 05410 Adjust Complete Denture - upper 05410 Adjust Complete Denture - upper 05411 Adjust Complete Denture - lower 05411 Adjust Complete Denture - lower 05411 Adjust Complete Denture - lower 05421 Adjust Partial Denture - upper 05421 Adjust Partial Denture - upper 05421 Adjust Partial Denture - upper 05422 Adjust Partial Denture - lower 05422 Adjust Partial Denture - lower 05422 Adjust Partial Denture - lower 05510 Repair broken complete denture base 05510 Repair broken complete denture base 05510 Repair broken complete denture base 05520 05520 05520 Replace missing or borken teeth complete denture (each tooth) Replace missing or borken teeth complete denture (each tooth) Replace missing or borken teeth complete denture (each tooth) 05610 Repair acrylic saddle or base 05610 Repair acrylic saddle or base 05610 Repair acrylic saddle or base 05620 Repair cast framework 05620 Repair cast framework 05620 Repair cast framework 05630 Repair or replace broken clasp 05630 Repair or replace broken clasp 05630 Repair or replace broken clasp 05640 Replace broken teeth (per tooth) 05640 Replace broken teeth (per tooth) 05640 Replace broken teeth (per tooth)
05650 Add tooth to existing partial denture 05650 Add tooth to existing partial denture 05650 Add tooth to existing partial denture 05660 Add clasp to existing partial denture 05660 Add clasp to existing partial denture 05660 Add clasp to existing partial denture 05710 Rebase complete upper denture 05710 Rebase complete upper denture 05710 Rebase complete upper denture 05711 Rebase complete lower denture 05711 Rebase complete lower denture 05711 Rebase complete lower denture 05720 Rebase upper partial denture 05720 Rebase upper partial denture 05720 Rebase upper partial denture 05721 Rebase lower partial denture 05721 Rebase lower partial denture 05721 Rebase lower partial denture 05730 Reline complete upper denture (chairside) 05730 Reline complete upper denture (chairside) 05730 Reline complete upper denture (chairside) 05731 Reline complete lower denture (chairside) 05731 Reline complete lower denture (chairside) 05731 Reline complete lower denture (chairside) 05740 Reline upper partial denture (chairside) 05740 Reline upper partial denture (chairside) 05740 Reline upper partial denture (chairside) 05741 Reline lower partial denture (chairside) 05741 Reline lower partial denture (chairside) 05741 Reline lower partial denture (chairside) 05750 Reline complete upper denture (laboratory) 05750 Reline complete upper denture (laboratory) 05750 Reline complete upper denture (laboratory) 05751 Reline complete lower denture (laboratory)
05751 Reline complete lower denture (laboratory) 05751 Reline complete lower denture (laboratory) 05760 Reline upper partial denture (laboratory) 05760 Reline upper partial denture (laboratory) 05760 Reline upper partial denture (laboratory) 05761 Reline lower partial denture (laboratory) 05761 Reline lower partial denture (laboratory) 05761 Reline lower partial denture (laboratory) 05810 Interim complete denture (upper) 05810 Interim complete denture (upper) 05810 Interim complete denture (upper) 05811 Interim complete denture (lower) 05811 Interim complete denture (lower) 05811 Interim complete denture (lower) 05820 Interim partial denture (upper) 05820 Interim partial denture (upper) 05820 Interim partial denture (upper) 05821 Interim partial denture (lower) 05821 Interim partial denture (lower) 05821 Interim partial denture (lower) 05850 Tissue conditioning (upper) 05850 Tissue conditioning (upper) 05850 Tissue conditioning (upper) 05851 Tissue conditioning (lower) 05851 Tissue conditioning (lower) 05851 Tissue conditioning (lower) 05860 Overdenture - complete 05860 Overdenture - complete 05860 Overdenture - complete 05861 Overdenture - partial 05861 Overdenture - partial 05861 Overdenture - partial 05862 Precision attachment 05862 Precision attachment
05862 Precision attachment 05899 05899 05899 06010 06010 06010 06020 06020 06020 Unspecified removable prosthodontic procedure Unspecified removable prosthodontic procedure Unspecified removable prosthodontic procedure Surgical placement of implant body - endosteal implant Surgical placement of implant body - endosteal implant Surgical placement of implant body - endosteal implant Abutment placement or substitution - endosteal implant Abutment placement or substitution - endosteal implant Abutment placement or substitution - endosteal implant 06055 Dental implant supported connecting bar 06055 Dental implant supported connecting bar 06055 Dental implant supported connecting bar 06080 06080 06080 Implant maintenance procedures, including: removal of prosthesis Implant maintenance procedures, including: removal of prosthesis Implant maintenance procedures, including: removal of prosthesis 06095 Repair implant abutment 06095 Repair implant abutment 06095 Repair implant abutment 06100 Implant removal 06100 Implant removal 06100 Implant removal 06199 Unspecified implant procedure 06199 Unspecified implant procedure 06199 Unspecified implant procedure
06210 Pontic - cast high noble metal 06210 Pontic - cast high noble metal 06210 Pontic - cast high noble metal 06211 Pontic - cast predominantly base metal 06211 Pontic - cast predominantly base metal 06211 Pontic - cast predominantly base metal 06212 Pontic - cast noble metal 06212 Pontic - cast noble metal 06212 Pontic - cast noble metal 06240 Pontic - porcelain fused to high noble metal 06240 Pontic - porcelain fused to high noble metal 06240 Pontic - porcelain fused to high noble metal 06241 06241 06241 Pontic - porcelain fused to predominantly base met Pontic - porcelain fused to predominantly base met Pontic - porcelain fused to predominantly base met 06242 Pontic - porcelain fused to noble metal 06242 Pontic - porcelain fused to noble metal 06242 Pontic - porcelain fused to noble metal 06520 Inlay - 2 surfaces, metallic 06520 Inlay - 2 surfaces, metallic 06520 Inlay - 2 surfaces, metallic 06530 Inlay - 3 or more surfaces, metallic 06530 Inlay - 3 or more surfaces, metallic 06530 Inlay - 3 or more surfaces, metallic 06545 06545 06545 Cast metal retainer for resin bonded fixed prosthe Cast metal retainer for resin bonded fixed prosthe Cast metal retainer for resin bonded fixed prosthe 06750 Crown - porcelain fused to high noble metal 06750 Crown - porcelain fused to high noble metal
06750 Crown - porcelain fused to high noble metal 06751 06751 06751 Crown - porcelain fused to predominantly base meta Crown - porcelain fused to predominantly base meta Crown - porcelain fused to predominantly base meta 06752 Crown - porcelain fused to noble metal 06752 Crown - porcelain fused to noble metal 06752 Crown - porcelain fused to noble metal 06780 Crown - 3/4 cast high noble metal 06780 Crown - 3/4 cast high noble metal 06780 Crown - 3/4 cast high noble metal 06790 Crown - full cast high noble metal 06790 Crown - full cast high noble metal 06790 Crown - full cast high noble metal 06791 Crown - full cast perdominantly base metal 06791 Crown - full cast perdominantly base metal 06791 Crown - full cast perdominantly base metal 06792 Crown - full cast noble metal 06792 Crown - full cast noble metal 06792 Crown - full cast noble metal 06920 Connector bar 06920 Connector bar 06920 Connector bar 06930 Recement bridge 06930 Recement bridge 06930 Recement bridge 06940 Stress breaker 06940 Stress breaker 06940 Stress breaker 06950 Precision attachment 06950 Precision attachment 06950 Precision attachment
06970 06970 06970 Cast post and core in addition to bridge retainer Cast post and core in addition to bridge retainer Cast post and core in addition to bridge retainer 06971 Cast post as part of bridge retainer 06971 Cast post as part of bridge retainer 06971 Cast post as part of bridge retainer 06972 06972 06972 Prefabricated post and core in addition to bridge Prefabricated post and core in addition to bridge Prefabricated post and core in addition to bridge 06999 Unspecified fixed prosthodontic procedure 06999 Unspecified fixed prosthodontic procedure 06999 Unspecified fixed prosthodontic procedure 07111 07111 07111 Extraction of coronal remnants - decidous tooth Extraction of coronal remnants - decidous tooth Extraction of coronal remnants - decidous tooth 07140 Extraction, erupted tooth or exposed tooth 07140 Extraction, erupted tooth or exposed tooth 07140 Extraction, erupted tooth or exposed tooth 07210 07210 07210 Surgical removal of erupted tooth requiring elevation Surgical removal of erupted tooth requiring elevation Surgical removal of erupted tooth requiring elevation 07220 Removal of impacted tooth - soft tissue 07220 Removal of impacted tooth - soft tissue 07220 Removal of impacted tooth - soft tissue 07230 Removal of impacted tooth partially bony
07230 Removal of impacted tooth partially bony 07230 Removal of impacted tooth partially bony 07240 Removal of impacted tooth completely bony 07240 Removal of impacted tooth completely bony 07240 Removal of impacted tooth completely bony 07241 07241 07241 07250 07250 07250 07280 07280 07280 07281 07281 07281 Removal of impacted tooth completely bony - with unusual surgical complications Removal of impacted tooth completely bony - with unusual surgical complications Removal of impacted tooth completely bony - with unusual surgical complications Surgical removal of residual tooth roots (cutting procedures) Surgical removal of residual tooth roots (cutting procedures) Surgical removal of residual tooth roots (cutting procedures) Surgical exposure of impacted or unerupted tooth f Surgical exposure of impacted or unerupted tooth f Surgical exposure of impacted or unerupted tooth f Surgical exposure of impacted or unerupted tooth t Surgical exposure of impacted or unerupted tooth t Surgical exposure of impacted or unerupted tooth t 07285 Biopsy of oral tissue - hard 07285 Biopsy of oral tissue - hard 07285 Biopsy of oral tissue - hard 07286 Biopsy of oral tissue - soft 07286 Biopsy of oral tissue - soft 07286 Biopsy of oral tissue - soft 07310 Alveoloplasty in conjuction with extractions - per Quadrant
07310 07310 07320 07320 07320 07340 07340 07340 07350 07350 07350 07440 07440 07440 07441 07441 07441 07450 07450 Alveoloplasty in conjuction with extractions - per Quadrant Alveoloplasty in conjuction with extractions - per Quadrant Alveoloplasty not in conjuction with extractions - Alveoloplasty not in conjuction with extractions - Alveoloplasty not in conjuction with extractions - Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (soft tissue gra Vestibuloplasty - ridge extension (soft tissue gra Vestibuloplasty - ridge extension (soft tissue gra Excision of malignant tumor-lesion diameter up to Excision of malignant tumor-lesion diameter up to Excision of malignant tumor-lesion diameter up to Excision of malignant tumor-lesion diameter greate Excision of malignant tumor-lesion diameter greate Excision of malignant tumor-lesion diameter greate Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion diamet 07450 Removal of odontogenic cyst or tumor-lesion
07451 07451 07451 07460 07460 07460 07461 07461 07461 07465 07465 07465 diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Destruction of lesion(s) by physical or chemical m Destruction of lesion(s) by physical or chemical m Destruction of lesion(s) by physical or chemical m 07470 Removal of exostosis-maxilla or mandible 07470 Removal of exostosis-maxilla or mandible 07470 Removal of exostosis-maxilla or mandible 07510 07510 07510 07520 07520 Incision and drainage of abcess-intraoral soft tis Incision and drainage of abcess-intraoral soft tis Incision and drainage of abcess-intraoral soft tis Incision and drainage of abcess-extraoral soft tis Incision and drainage of abcess-extraoral soft tis
07520 Incision and drainage of abcess-extraoral soft tis 07910 Suture of recent small wounds up to 5 cm 07910 Suture of recent small wounds up to 5 cm 07910 Suture of recent small wounds up to 5 cm 07911 Complicated suture up to 5 cm 07911 Complicated suture up to 5 cm 07911 Complicated suture up to 5 cm 07912 Complicated suture greater than 5 cm 07912 Complicated suture greater than 5 cm 07912 Complicated suture greater than 5 cm 07960 07960 07960 Frenulectomy (frenectomy or frenotomy) - separate Frenulectomy (frenectomy or frenotomy) - separate Frenulectomy (frenectomy or frenotomy) - separate 07970 Excision of hyperplastic tissue - per arch 07970 Excision of hyperplastic tissue - per arch 07970 Excision of hyperplastic tissue - per arch 07971 Excision of pericoronal gingiva 07971 Excision of pericoronal gingiva 07971 Excision of pericoronal gingiva 07999 Unspecified oral surgery procedure 07999 Unspecified oral surgery procedure 07999 Unspecified oral surgery procedure 08010 08010 08010 08020 08020 Limited orthodontic treatment of the primary denti Limited orthodontic treatment of the primary denti Limited orthodontic treatment of the primary denti Limited orthodontic treatment of the transitional Limited orthodontic treatment of the transitional
08020 08030 08030 08030 08040 08040 08040 08050 08050 08050 08060 08060 08060 08070 08070 08070 08080 08080 08080 Limited orthodontic treatment of the transitional Limited orthodontic treatment of the adolescent de Limited orthodontic treatment of the adolescent de Limited orthodontic treatment of the adolescent de Limited orthodontic treatment of the adult dentiti Limited orthodontic treatment of the adult dentiti Limited orthodontic treatment of the adult dentiti Interceptive orthodontic treatment of the primary Interceptive orthodontic treatment of the primary Interceptive orthodontic treatment of the primary Interceptive orthodontic treatment of the transiti Interceptive orthodontic treatment of the transiti Interceptive orthodontic treatment of the transiti Comprehensive orthodontic treatment of the transit Comprehensive orthodontic treatment of the transit Comprehensive orthodontic treatment of the transit Orthodontic Braces by General dentist - children under age 19 Orthodontic Braces by General dentist - children under age 19 Orthodontic Braces by General dentist - children under age 19 08090 Orthodontic Braces by General dentist - adult
08090 08090 19 and over Orthodontic Braces by General dentist - adult 19 and over Orthodontic Braces by General dentist - adult 19 and over 08210 Retainers (each up to 2 years) 08210 Retainers (each up to 2 years) 08210 Retainers (each up to 2 years) 08220 Maxillary expansion 08220 Maxillary expansion 08220 Maxillary expansion 08660 08660 08660 Diagnostic workup including cephalometric, panoram Diagnostic workup including cephalometric, panoram Diagnostic workup including cephalometric, panoram 08670 Periodic orthodontic treatment visit 0% 08670 Periodic orthodontic treatment visit 0% 08670 Periodic orthodontic treatment visit 0% 08680 08680 08680 Orthodontic retention (removal of appliances, cons Orthodontic retention (removal of appliances, cons Orthodontic retention (removal of appliances, cons 08999 Unspecified orthodontic procedure by report 08999 Unspecified orthodontic procedure by report 08999 Unspecified orthodontic procedure by report 00016 Failed appointment (without 24 hr. notice) 00016 Failed appointment (without 24 hr. notice) 00016 Failed appointment (without 24 hr. notice) 09110 09110 Palliative (emergency) treatment of dental pain - Palliative (emergency) treatment of dental pain -
09110 09210 09210 09210 Palliative (emergency) treatment of dental pain - Local anesthesia not in conjuction with operative Local anesthesia not in conjuction with operative Local anesthesia not in conjuction with operative 09215 Local anesthesia 09215 Local anesthesia 09215 Local anesthesia 09230 Analgesia 09230 Analgesia 09230 Analgesia 09240 Intravenous sedation 09240 Intravenous sedation 09240 Intravenous sedation 09310 09310 09310 09430 09430 09430 Consultation - per session (diagnostic service pro Consultation - per session (diagnostic service pro Consultation - per session (diagnostic service pro Office visit for observation (during regularly sch Office visit for observation (during regularly sch Office visit for observation (during regularly sch 09440 Office visit - after regularly scheduled hours 09440 Office visit - after regularly scheduled hours 09440 Office visit - after regularly scheduled hours 09941 fabrication of athletic mouthguard 09941 fabrication of athletic mouthguard 09941 fabrication of athletic mouthguard 09950 Occlusion analysis (mounted case)
09950 Occlusion analysis (mounted case) 09950 Occlusion analysis (mounted case) 09951 Occlusal adjustment (limited) 09951 Occlusal adjustment (limited) 09951 Occlusal adjustment (limited) 09952 Occlusal adjustment (complete) 09952 Occlusal adjustment (complete) 09952 Occlusal adjustment (complete) Invisalign Braces may not be included.