TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver D0150 Comprehensive oral evaluation - new or established patient 47.95 D0160 Detailed and extensive oral evaluation - problem focused, by report 79.60 D0170 Re-evaluation - limited, problem focused (established patient; 42.30 not post-operative visit) D0180 Comprehensive periodontal evaluation - new or established 59.94 patient D0210 Intraoral - complete series (including bitewings) 82.47 D0220 Intraoral - periapical first film 16.30 D0230 Intraoral - periapical each additional film 13.43 D0240 Intraoral - occlusal film 25.89 D0250 Extraoral - first film 35.48 D0260 Extraoral - each additional film 28.77 D0270 Bitewing - single film 16.30 D0272 Bitewings - two films 26.85 D0273 Bitewings - three films 33.22 D0274 Bitewings - four films 38.36 D0277 Vertical bitewings - 7 to 8 films 72.82 D0290 Posterior-anterior or lateral skull and facial bone survey film 79.60 D0310 Sialography 143.85 D0321 Other temporomandibular joint films, by report 129.46 D0330 Panoramic film 71.92 D0415 Bacteriologic studies for determination of pathologic agents 77.68 D0460 Pulp vitality tests 35.48 D0470 Diagnostic casts 62.33 D1110 Prophylaxis - adult 56.58 D1120 Prophylaxis - child 41.24 D1203 Topical application of fluoride (prophylaxis not included) - 23.02 child D1204 Topical application of fluoride (prophylaxis not included) - 23.02 adult D1206 Topical fluoride varnish; therapeutic application for moderate 23.02 to high caries risk patients D1351 Sealant - per tooth 33.56 D1510 Space maintainer - fixed - unilateral 207.14 D1515 Space maintainer - fixed - bilateral 288.65 D1520 Space maintainer - removable - unilateral 255.21 D1525 Space maintainer - removable - bilateral 339.56 D1550 Re-cementation of space maintainer 50.83 D1555 Removal of fixed space maintainer 50.83 TYPE 2 D2140 Amalgam - one surface, primary or permanent 57.84 D2150 Amalgam - two surfaces, primary or permanent 73.62 Page 1
D2160 Amalgam - three surfaces, primary or permanent 90.14 D2161 Amalgam - four or more surfaces, primary or permanent 109.67 D2330 Resin-based composite - one surface, anterior 71.36 D2331 Resin-based composite - two surfaces, anterior 89.39 D2332 Resin-based composite - three surfaces, anterior 110.42 D2335 Resin-based composite - four or more surfaces or involving 138.22 incisal angle (anterior) D2390 Resin-based composite crown, anterior 160.75 D2391 Resin-based composite - one surface, posterior 78.12 D2410 Gold foil - one surface 218.34 D2420 Gold foil - two surfaces 303.94 D2430 Gold foil - three surfaces 377.93 D3110 Pulp cap - direct (excluding final restoration) 37.56 D3120 Pulp cap - indirect (excluding final restoration) 36.81 D3220 Therapeutic pulpotomy (excluding final restoration) - removal 88.64 of pulp coronal to the dentinocemental junction and application of medicament D3221 Pulpal debridement, primary and permanent teeth 63.10 D3222 Partial Pulpotomy for Apexogenesis - Permanent Tooth with 88.64 Incomplete Root Development D3310 Anterior (excluding final restoration) 332.77 D3320 Bicuspid (excluding final restoration) 401.88 D3330 Molar (excluding final restoration) 496.53 D3333 Internal root repair of perforation defects 105.75 D3346 Retreatment of previous root canal therapy - anterior 371.84 D3347 Retreatment of previous root canal therapy - bicuspid 432.76 D3348 Retreatment of previous root canal therapy - molar 529.58 D3351 Apexification/recalcification - initial visit (apical 168.27 closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy/periradicular surgery - anterior 311.74 D3421 Apicoectomy/periradicular surgery - bicuspid (first root) 355.31 D3425 Apicoectomy/periradicular surgery - molar (first root) 405.64 D3426 Apicoectomy/periradicular surgery (each additional root) 236.52 D3430 Retrograde filling - per root 121.69 D3450 Root amputation - per root 219.35 D3910 Surgical procedure for isolation of tooth with rubber dam 124.10 D3920 Hemisection (including any root removal), not including root 214.09 canal therapy D4210 Gingivectomy or gingivoplasty - four or more contiguous 304.23 teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty - one to three teeth, per 102.16 quadrant D4240 Gingival flap procedure, including root planing - four or more 365.08 contiguous teeth or bounded teeth spaces per quadrant D4241 Gingival flap procedure, including root planing - one to three 273.81 teeth, per quadrant D4249 Clinical crown lengthening - hard tissue 361.32 D4260 Osseous surgery (including flap entry and closure) - four or 527.33 more contiguous teeth or bounded teeth spaces per Page 2
D4261 Osseous surgery (including flap entry and closure) - 1-3 395.50 teeth/quadrant D4263 Bone replacement graft - first site in quadrant 326.01 D4264 Bone replacement graft - each additional site in quadrant 238.88 D4265 Biologic materials to aid in soft and osseous tissue 326.01 regeneration D4266 Guided tissue regeneration - resorbable barrier, per site 446.20 D4267 Guided tissue regeneration - nonresorbable barrier, per site 527.33 (includes membrane removal) D4268 Surgical revision procedure, per tooth 392.87 D4270 Pedicle soft tissue graft procedure 394.37 D4271 Free soft tissue graft procedure (including donor site surgery) 426.67 D4273 Subepithelial connective tissue graft procedures 534.09 D4274 Distal or proximal wedge procedure (when not performed in 334.28 conjunction with surgical procedures in the same anatomical area) D4275 Soft tissue allograft 534.09 D4276 Combined connective tissue and double pedicle graft 534.09 D4341 Periodontal scaling and root planing - four or more 125.45 contiguous teeth or bounded teeth spaces per quadrant D4342 Periodontal scaling and root planing - one to three teeth/ 94.09 quadrant D4355 Full mouth debridement to enable comprehensive evaluation 84.88 and diagnosis D4910 Periodontal maintenance 69.11 D5410 Adjust complete denture - maxillary 39.17 D5411 Adjust complete denture - mandibular 39.17 D5421 Adjust partial denture - maxillary 39.17 D5422 Adjust partial denture - mandibular 39.17 D5510 Repair broken complete denture base 94.30 D5520 Replace missing or broken teeth - complete denture (each 78.34 tooth) D5610 Repair resin denture base 90.67 D5620 Repair cast framework 137.10 D5630 Repair or replace broken clasp 117.51 D5640 Replace broken teeth - per tooth 78.34 D5650 Add tooth to existing partial denture 101.56 D5660 Add clasp to existing partial denture 129.85 D5670 Replace all teeth and acrylic on cast metal framework 521.75 (maxillary) D5671 Replace all teeth and acrylic on cast metal framework 511.77 (mandibular) D5710 Rebase complete maxillary denture 274.20 D5711 Rebase complete mandibular denture 270.57 D5720 Rebase maxillary partial denture 263.32 D5721 Rebase mandibular partial denture 259.69 D5730 Reline complete maxillary denture (chairside) 163.94 D5731 Reline complete mandibular denture (chairside) 164.67 D5740 Reline maxillary partial denture (chairside) 156.69 D5741 Reline mandibular partial denture (chairside) 157.41 Page 3
D5750 Reline complete maxillary denture (laboratory) 225.60 D5751 Reline complete mandibular denture (laboratory) 224.87 D5760 Reline maxillary partial denture (laboratory) 221.97 D5761 Reline mandibular partial denture (laboratory) 222.70 D5820 Interim partial denture (maxillary) 551.69 D5821 Interim partial denture (mandibular) 551.69 D5850 Tissue conditioning, maxillary 84.15 D5851 Tissue conditioning, mandibular 84.15 D7111 Coronal remnants, deciduous tooth 27.81 D7140 Extraction, erupted tooth or exposed root (elevation and/or 71.36 forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of 133.71 mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth - soft tissue 166.08 D7230 Removal of impacted tooth - partially bony 213.53 D7240 Removal of impacted tooth - completely bony 279.96 D7241 Removal of impacted tooth - completely bony, with unusual 283.95 surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) 141.97 D7260 Oroantral fistula closure 327.52 D7261 Primary closure of a sinus perforation 327.52 D7270 Tooth reimplantation and/or stabilization of accidentally 243.38 evulsed or displaced tooth D7272 Tooth transplantation (includes reimplantation from one site 328.27 to another and splinting and/or stabilization) D7280 Surgical access of an unerupted tooth 275.21 D7283 Placement of device to facilitate eruption of impacted tooth 121.00 D7285 Biopsy of oral tissue - hard (bone, tooth) 242.94 D7286 Biopsy of oral tissue - soft (all others) 242.94 D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report 127.70 D7310 Alveoloplasty in conjunction with extractions - per quadrant 142.35 D7311 Alveoloplasty in conjunction with extractions 1 to 3 teeth or 142.35 tooth spaces per quad D7320 Alveoloplasty not in conjunction with extractions - per 213.53 quadrant D7321 Alveoloplasty not in conjunction with extractions 1 to 3 teeth 213.53 or tooth spaces per quad D7340 Vestibuloplasty - ridge extension (secondary epithelialization) 325.26 D7350 Vestibuloplasty - ridge extension (including soft tissue grafts, 822.55 muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) D7410 Excision of benign lesion up to 1.25 cm 201.32 D7411 Excision of benign lesion greater than 1.25 cm 283.95 D7412 Excision of benign lesion, complicated 354.94 D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm 274.93 D7441 Excision of malignant tumor - lesion diameter greater than 494.28 1.25 cm Page 4
D7450 Removal of benign odontogenic cyst or tumor - lesion 243.38 diameter up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor - lesion 320.00 diameter greater than 1.25 cm D7460 Removal of benign nonodontogenic cyst or tumor - lesion 239.63 diameter up to 1.25 cm D7461 Removal of benign nonodontogenic cyst or tumor - lesion 327.52 diameter greater than 1.25 cm D7465 Destruction of lesion(s) by physical or chemical method, by 170.52 report D7471 Removal of lateral exostosis (maxilla or mandible) 321.74 D7472 Removal of torus palatinus 321.71 D7473 Removal of torus mandibularis 321.71 D7485 Surgical reduction of osseous tuberosity 321.71 D7510 Incision and drainage of abscess - intraoral soft tissue 101.41 D7511 Incision and drainage of abcess intraoral soft tissue 101.41 complicated D7520 Incision and drainage of abscess - extraoral soft tissue 167.51 D7521 Incision and drainage of abcess extraoral soft tissue 167.51 complicated D7530 Removal of foreign body from mucosa, skin, or 158.50 subcutaneous alveolar tissue D7540 Removal of reaction producing foreign bodies, 245.64 musculoskeletal system D7550 Partial ostectomy/sequestrectomy for removal of non-vital 238.88 bone D7670 Alveolus closed reduction may include stabilization of teeth 662.54 D7770 Alveolus - open reduction stabilization of teeth 1,183.11 D7820 Closed reduction of dislocation 205.82 D7830 Manipulation under anesthesia 313.24 D7870 Arthrocentesis 959.93 D7911 Complicated suture - up to 5 cm 202.82 D7960 Frenulectomy (frenectomy or frenotomy) - separate 237.25 procedure D7963 Frenuoplasty 237.21 D9110 Palliative (emergency) treatment of dental pain - minor 57.09 procedure D9120 Fixed partial denture sectioning 83.67 D9220 Deep sedation/general anesthesia - first 30 minutes 181.04 D9241 Intravenous conscious sedation/analgesia - first 30 minutes 174.27 D9242 Intravenous conscious sedation/analgesia - each additional 63.85 15 minutes D9910 Application of desensitizing medicament 30.80 D9940 Occlusal guard, by report 295.22 D9951 Occlusal adjustment - limited 77.37 TYPE 3 D2510 Inlay - metallic - one surface 215.88 D2520 Inlay - metallic - two surfaces 248.09 D2530 Inlay - metallic - three or more surfaces 275.18 Page 5
D2542 Onlay - metallic-two surfaces 290.00 D2543 Onlay - metallic-three surfaces 297.27 D2544 Onlay - metallic-four or more surfaces 310.33 D2610 Inlay - porcelain/ceramic - one surface 246.78 D2620 Inlay - porcelain/ceramic - two surfaces 265.49 D2630 Inlay - porcelain/ceramic - three or more surfaces 283.34 D2642 Onlay - porcelain/ceramic - two surfaces 295.96 D2643 Onlay - porcelain/ceramic - three surfaces 310.33 D2644 Onlay - porcelain/ceramic - four or more surfaces 370.44 D2650 Inlay - resin-based composite - one surface 223.28 D2651 Inlay - resin-based composite - two surfaces 246.78 D2652 Inlay - resin-based composite - three or more surfaces 265.49 D2662 Onlay - resin-based composite - two surfaces 282.04 D2663 Onlay - resin-based composite - three surfaces 286.82 D2664 Onlay - - resin-based composite - four or more surfaces 300.75 D2710 Crown - resin (indirect) 218.49 D2720 Crown - resin with high noble metal 313.37 D2721 Crown - resin with predominantly base metal 282.04 D2722 Crown - resin with noble metal 297.27 D2740 Crown - porcelain/ceramic substrate 333.83 D2750 Crown - porcelain fused to high noble metal D2751 Crown - porcelain fused to predominantly base metal 295.96 D2752 Crown - porcelain fused to noble metal 306.85 D2780 Crown - 3/4 cast high noble metal 326.86 D2781 Crown - 3/4 cast predominantly base metal 292.04 D2782 Crown - 3/4 cast noble metal 306.85 D2783 Crown - 3/4 porcelain/ceramic 370.44 D2790 Crown - full cast high noble metal D2791 Crown - full cast predominantly base metal 288.56 D2792 Crown - full cast noble metal D2799 Provisional crown 80.95 D2910 Recement inlay 28.67 D2920 Recement crown 28.73 D2930 Prefabricated stainless steel crown - primary tooth 83.13 D2931 Prefabricated stainless steel crown - permanent tooth 91.84 D2932 Prefabricated resin crown 92.27 D2933 Prefabricated stainless steel crown with resin window 105.76 D2940 Sedative filling 30.03 D2950 Core buildup, including any pins 77.47 D2951 Pin retention - per tooth, in addition to restoration 21.79 D2952 Cast post and core in addition to crown 125.35 D2954 Prefabricated post and core in addition to crown 94.01 D2970 Temporary crown (fractured tooth) 82.26 D2980 Crown repair, by report 99.18 D5110 Complete denture - maxillary 434.80 D5120 Complete denture - mandibular 433.93 D5130 Immediate denture - maxillary 458.30 D5140 Immediate denture - mandibular 457.43 D5211 Maxillary partial denture - resin base (including any 338.18 conventional clasps, rests and teeth) Page 6
D5212 Mandibular partial denture - resin base (including any 340.79 conventional clasps, rests and teeth) D5213 Axillary partial denture - cast metal framework with resin 459.18 denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture - cast metal framework with resin 458.30 denture bases (including any conventional clasps, rests and teeth) D5225 Maxillary Partial Denture - Flexible Base 459.18 D5226 Mandibular Partial Denture - Flexible Base 458.30 D5281 Removable unilateral partial denture - one piece cast metal 263.75 (including clasps and teeth) D6056 Prefabricated abutment 125.35 D6057 Custom Abutment 125.35 D6058 Implant Abut Crown 333.83 D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Implant Abut Crown 295.96 D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Implant Abut Crown D6063 Implant Abut Crown 288.56 D6064 Implant Abut Crown D6065 Implant Abut Crown 333.83 D6066 Implant Abut Crown D6067 Implant Abut Crown D6069 Abutment supported reainer for porcelain fused to metal FPD (high noble metal) D6070 Abutment supported reainer for porcelain fused to metal FPD 295.96 (predominately base metal) D6071 Abutment supported reainer for porcelain fused to metal FPD 306.85 (noble metal) D6072 Abutment supported reainer for cast metal FPD (high noble metal) D6073 Abutment supported reainer for cast metal FPD 288.56 (predominately base metal) D6074 Abutment supported reainer for cast metal FPD (noble metal) D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) D6078 Implant/abutment supported fixed denture for completely 434.80 edentulous arch D6079 Implant/abutment supported fixed denture for partially 459.18 edentulous arch D6092 recement implant/abutment supported crown 30.00 D6093 recement implant/abutment supported fixed partial denture 48.60 D6094 Abutment supported crown - titanium D6194 Abutment supported retainer crown for FPD - titanium Page 7
D6205 Pontic - indirect resin based composite 322.51 D6210 Pontic - cast high noble metal 312.07 D6211 Pontic - cast predominantly base metal 286.82 D6212 Pontic - cast noble metal 298.57 D6214 Pontic - titanium 312.07 D6240 Pontic - porcelain fused to high noble metal 319.03 D6241 Pontic - porcelain fused to predominantly base metal 293.78 D6242 Pontic - porcelain fused to noble metal D6250 Pontic - resin with high noble metal D6251 Pontic - resin with predominantly base metal 293.78 D6252 Pontic - resin with noble metal D6545 Retainer - cast metal for resin bonded fixed prosthesis 185.85 D6602 Inlay - cast high noble metal, two surfaces" 248.09 D6603 Inlay - cast high noble metal, three or more surfaces 275.18 D6604 Inlay - cast predominantly base metal, two surfaces 244.60 D6605 Inlay - cast predominantly base metal, three or more surfaces 263.32 D6606 Inlay - cast noble metal, two surfaces 244.60 D6607 Inlay - cast noble metal, three or more surfaces 263.32 D6610 Onlay - cast high noble metal, two surfaces 299.44 D6611 Onlay - cast high noble metal, three or more surfaces 314.68 D6612 Onlay - cast predominantly base metal, two surfaces 299.44 D6613 Onlay - cast predominantly base metal, three or more surfaces 314.68 D6614 Onlay - cast noble metal, two surfaces 299.44 D6615 Onlay - cast noble metal, three or more surfaces 314.68 D6624 Inlay - titanium 54.08 D6634 Onlay - titanium 314.68 D6710 Crown - indirect resin based composite 322.51 D6720 Crown - resin with high noble metal 311.63 D6721 Crown - resin with predominantly base metal 290.74 D6722 Crown - resin with noble metal 304.67 D6750 Crown - porcelain fused to high noble metal 322.51 D6751 Crown - porcelain fused to predominantly base metal 293.78 D6752 Crown - porcelain fused to noble metal D6780 Crown - 3/4 cast high noble metal 308.59 D6781 Crown - 3/4 cast predominantly base metal 315.98 D6782 Crown - 3/4 cast noble metal 318.59 D6790 Crown - full cast high noble metal D6791 Crown - full cast predominantly base metal 286.82 D6792 Crown - full cast noble metal D6794 Crown - titanium D6930 Recement fixed partial denture 42.22 D6970 Cast post and core in addition to fixed partial denture retainer 121.00 D6972 Prefabricated post and core in addition to fixed partial denture retainer 91.84 D6973 Core build up for retainer, including any pins 78.34 D6980 Fixed partial denture repair, by report 102.28 Page 8