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Detailed narrative explaining the treatment provided in order to determine allowance. Narrative must be submitted with claim.

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Procedure Code (CDT) Procedure Code (CDT) Description In-Network Plan Allowance * Out-of-Network Plan Allowance *
D0120 PERIODIC ORAL EVALUATION EST PT $31.00 $18.00
D0140 LTD ORAL EVALUATION - PROBLEM FOCUS $47.00 $28.00
D0145 ORL EVAL PT<3 YR CNSL PRIM CAREGIVR $58.00 $42.00
D0150 COMP ORAL EVALUATION - NEW/EST PT $47.00 $27.00
D0160 DTL&EXT ORAL EVAL - PROB FOCUS RPT $152.00 $110.00
D0170 RE-EVALUATION - LTD PROBLEM FOCUSED $37.00 $27.00
D0171 RE-EVALUATION-POST-OP OFFICE VISIT $37.00 $27.00
D0180 COMP PERIODONTAL EVAL - NEW/EST PT $47.00 $27.00
D0190 SCREENING OF A PATIENT BY REPORT BY REPORT
D0191 ASSESSMENT OF A PATIENT BY REPORT BY REPORT
D0210 INTRAORAL-CMPL SER RADIOGRAPH IMAGS $110.00 $76.00
D0220 IO-PERIAPICAL 1ST RADIOGRAPHC IMAGE $16.00 $12.00
D0230 IO-PERIAPICAL EA ADD RADIOGRPH IMAG $15.00 $7.00
D0240 INTRAORAL-OCCLUSAL RADIOGRAPH IMAGE $26.00 $7.00
D0250 EXTRA-ORAL - 2D PROJECTION X-RAY $37.00 $13.00
D0251 EXTRA-ORAL POSTERIOR DENTAL X-RAY NOT COVERED NOT COVERED
D0260 EXTRA-ORAL - EACH ADD RADIOGRAPH IMAGE $26.00 $5.50
D0270 BITEWING - SINGLE RADIOGRAPHC IMAGE $16.00 $12.00
D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES $26.00 $18.00
D0273 BITEWINGS-THREE RADIOGRAPHIC IMAGES $34.00 $25.00
D0274 BITEWINGS - FOUR RADIOGRAPHC IMAGES $37.00 $27.00
D0277 VERT BITEWNGS - 7-8 RADIOGRAPH IMAG $57.00 $33.00
D0290 POST-ANT/LATERAL SKULL & FACIAL BONE SURVEY FILM BY REPORT BY REPORT
D0310 SIALOGRAPHY $361.00 $24.00
D0320 TMJ ARTHROGRAM INCLUDING INJ BY REPORT BY REPORT
D0321 OTH TMJ FILMS BY REPORT $83.00 $8.00
D0322 TOMOGRAPHIC SURVEY BY REPORT BY REPORT
D0330 PANORAMIC RADIOGRAPHIC IMAGE $67.00 $39.00
D0340 2D CEPHALOMET X-RAY-ACQN MSR&ANALY $78.00 $28.00
D0350 ORAL/FACIAL PHOTOGRAPH IMAGES IO/EO $129.00 $60.00
D0351 3D PHOTOGRAPHIC IMAGE BY REPORT BY REPORT
D0360 CONE BEAM CT - CRANIOFACIAL DATA CAPTURE BY REPORT BY REPORT
D0362 CONE BEAM 2-D RECONST EXISTING DATA MULTI IMAGES BY REPORT BY REPORT
D0363 CONE BEAM 3-D RECONST EXISTING DATA MULTI IMAGES BY REPORT BY REPORT
D0364 CONE BM CT CAP&INT LTD FD VW<1 W JW $258.00 $189.00
D0365 CONE BEAM CT 1 FULL DENT ARCH-MAND $258.00 $189.00
D0366 CONE BEAM CT 1 FULL DENT ARCH-MAX $258.00 $189.00
D0367 CONE BEAM CT CAP&INT FD VW BOTH JWS $258.00 $189.00
D0368 CONE BM CT CAP&INT TMJ SER2/>EXPOS BY REPORT BY REPORT
D0369 MAXILLOFACIAL MRI CAP & INTERPRET BY REPORT BY REPORT
D0370 MAXILLOFACIAL U/S CAP & INTERPRET BY REPORT BY REPORT
D0371 SIALOENDOSCOPY CAP & INTERPRETATION BY REPORT BY REPORT
D0380 CONE BEAM CT IMAG LTD FD VW<1 W JAW BY REPORT BY REPORT
D0381 CONE BEAM CT 1 FULL DENT ARCH-MAND BY REPORT BY REPORT
D0382 CONE BEAM CT 1 FULL DENT ARCH-MAX BY REPORT BY REPORT
D0383 CONE BEAM CT CAP FD VIEW BOTH JAWS $258.00 $189.00
D0384 CONE BM CT IMAG CAP TMJ SER2/>EXPOS BY REPORT BY REPORT
D0385 MAXILLOFACIAL MRI IMAGE CAPTURE BY REPORT BY REPORT
D0386 MAXILLOFACIAL ULTRASOUND IMAGE CAP BY REPORT BY REPORT
D0391 INT DX IMAG P NOT ASSO CAP IMAG RPT BY REPORT BY REPORT
D0393 TX SIMULATION 3D IMAGE VOLUME BY REPORT BY REPORT
D0394 DIGTL SUBTR 2/> IMAGES/VOL SAME MOD BY REPORT BY REPORT
D0395 FUSION 2/> 3D IMAG VOL 1/> MODAL BY REPORT BY REPORT
D0411 HBA1C IN-OFFICE POINT OF SERVICE TESTING BY REPORT BY REPORT
D0414 LAB PROC MICROB SPEC INC C & S STS BY REPORT BY REPORT
D0415 COLLECT MICROORAGNISMS CULT & SENS BY REPORT BY REPORT
D0416 VIRAL CULTURE BY REPORT BY REPORT
D0417 CLCT & PREP SALIV SAMP LAB DX TEST BY REPORT BY REPORT
D0418 ANALYSIS OF SALIVA SAMPLE BY REPORT BY REPORT
D0421 GENETIC TEST FOR SUSCEPTIBILITY TO ORAL DISEASES BY REPORT BY REPORT
D0422 CLCT & PREP GENETIC SAMPLE MATERIAL BY REPORT BY REPORT
D0423 GENETIC TEST SUSCEPT DZ-DPEC ANALY BY REPORT BY REPORT
D0425 CARIES SUSCEPTIBILITY TESTS BY REPORT BY REPORT
D0431 ADJUNCT PREDX TST NO CYTOL/BX PROC BY REPORT BY REPORT
D0460 PULP VITALITY TESTS NOT COVERED NOT COVERED
D0470 DIAGNOSTIC CASTS $62.00 $40.00
D0472 ACCESS TISS-GROSS EXAM-PREP & REPRT BY REPORT BY REPORT
D0473 ACCESS TISS-GROSS/MICRO-PREP/REPRT $109.00 $81.00
D0474 ACCESS TISS GR&MIC SURG MARG PREP/RPT $114.00 $82.50
D0475 DECALCIFICATION PROCEDURE BY REPORT BY REPORT
D0476 SPECIAL STAINS FOR MICROORGANISMS BY REPORT BY REPORT
D0477 SPECIAL STAINS NOT MICROORGANISMS BY REPORT BY REPORT
D0478 IMMUNOHISTOCHEMICAL STAINS BY REPORT BY REPORT
D0479 TISS INSITU HYBRIDIZATION W/INTEPR BY REPORT BY REPORT
D0480 ACESS EXFOLIATIVE CYT SMER MIC EXAM BY REPORT BY REPORT
D0481 ELECTRON MICROSCOPY DIAGNOSTIC BY REPORT BY REPORT
D0482 DIRECT IMMUNOFLUORESCENCE BY REPORT BY REPORT
D0483 INDIRECT IMMUNOFLUORESCENCE BY REPORT BY REPORT
D0484 CONSULTATION SLIDES PREPARED ELSW BY REPORT BY REPORT
D0485 CNSLT W/PREP SLIDES BX SPL REF SRC BY REPORT BY REPORT
D0486 LAB ACCSS TRNSEPI CYTL SMP MICRO EX BY REPORT BY REPORT
D0502 OTHER ORAL PATHOLOGY PROC REPORT BY REPORT BY REPORT
D0600 NON-IONIZ DX P CPBL QUANTIF MON & R NOT COVERED NOT COVERED
D0601 CARIES RISK ASSESS DOC FIND LOW RSK NOT COVERED NOT COVERED
D0602 CARIES RISK ASSESS DOC FIND MOD RSK NOT COVERED NOT COVERED
D0603 CARIES RISK ASSESS DOC FIND HI RSK NOT COVERED NOT COVERED
D0999 UNSPEC DIAGNOSTIC PROCEDURE REPORT NOT COVERED NOT COVERED
D1110 PROPHYLAXIS - ADULT $57.00 $39.00
D1120 PROPHYLAXIS - CHILD $46.00 $36.00
D1203 TOPICAL APPLICATION OF FLUORIDE CHILD $20.00 $20.00
D1204 TOPICAL APPLICATION OF FLUORIDE ADULT $22.00 $22.00
D1206 TOPICAL APPLICATION FLUORIDE VARNISH $22.00 $7.00
D1208 TOPICAL APPLICATION OF FLUORIDE $23.00 $7.00
D1310 NUTRITION COUNSEL CONTROL DENTAL DZ BY REPORT BY REPORT
D1320 TOBACCO CNSL CNTRL&PREVION ORL DZ BY REPORT BY REPORT
D1330 ORAL HYGIENE INSTRUCTIONS BY REPORT BY REPORT
D1351 SEALANT - PER TOOTH $31.00 $22.00
D1352 PREV RSN REST MOD HIGH CARIES RISK BY REPORT BY REPORT
D1353 SEALANT REPAIR - PER TOOTH BY REPORT BY REPORT
D1354 INTERIM CARIES ARRESTING MED APPLIC BY REPORT BY REPORT
D1510 SPACE MAINTAINER - FIXED-UNILATERAL $258.00 $83.00
D1515 SPACE MAINTAINER - FIXED-BILATERAL $258.00 $83.00
D1520 SPACE MAINTAINER - REMOVABLE-UNI $258.00 $83.00
D1525 SPACE MAINTAINER - REMOVABLE-BIL $258.00 $83.00
D1550 RECEMENTATION OF SPACE MAINTAINER $44.00 $30.00
D1555 REMOVAL OF FIXED SPACE MAINTAINER $42.00 $31.00
D1575 DISTAL SHOE SPACE MAINT-FIXED-UNI $300.00 $225.00
D1999 UNS PREVENTIVE PROCEDURE BY REPORT $10.00 $7.00
D2140 AMALGAM-ONE SURFACE PRIMARY/PERM $67.00 $47.00
D2150 AMALGAM-TWO SURFACES PRIMARY/PERM $88.00 $56.00
D2160 AMALGAM-3 SURFACES PRIMARY/PERM $103.00 $66.00
D2161 AMALGAM-FOUR/MORE SURF PRIM/PERM $129.00 $76.00
D2330 RESIN-BASED COMPOSITE ONE SURF ANT $83.00 $65.00
D2331 RESIN-BASED COMPOSITE 2 SURFACE ANT $124.00 $85.00
D2332 RESIN-BASED COMPOSITE 3 SURFACE ANT $155.00 $100.00
D2335 RESIN COMP 4/> SURF INCISAL ANGLE $191.00 $100.00
D2390 RESIN COMPOS CROWN ANTERIOR $206.00 $150.00
D2391 RESIN COMPOS - 1 SURFACE POSTERIOR $83.00 $65.00
D2392 RESIN COMPOS - 2 SURFACES POSTERIOR $124.00 $85.00
D2393 RESIN COMPOS - 3 SURFACES POSTERIOR $155.00 $100.00
D2394 RESIN COMPOS - 4/MORE SURFACES POST $191.00 $100.00
D2410 GOLD FOIL - ONE SURFACE NOT COVERED NOT COVERED
D2420 GOLD FOIL - TWO SURFACES NOT COVERED NOT COVERED
D2430 GOLD FOIL - THREE SURFACES NOT COVERED NOT COVERED
D2510 INLAY - METALLIC - ONE SURFACE $309.00 $120.00
D2520 INLAY - METALLIC - TWO SURFACES $412.00 $120.00
D2530 INLAY - METALLIC - 3/MORE SURFACES $464.00 $120.00
D2542 ONLAY - METALLIC - TWO SURFACES $412.00 $160.00
D2543 ONLAY METALLIC THREE SURFACES $464.00 $160.00
D2544 ONLAY METALLIC FOUR OR MORE SURF $618.00 $160.00
D2610 INLAY - PORCELN/CERAMIC - 1 SURFACE $309.00 $72.00
D2620 INLAY - PORCELN/CERAMIC - 2 SURF $412.00 $160.00
D2630 INLAY - PORCELN/CERAM - 3/MORE SURF $464.00 $160.00
D2642 ONLAY - PORCELN/CERAMIC - 2 SURF $412.00 $160.00
D2643 ONLAY - PORCELN/CERAMIC - 3 SURF $464.00 $160.00
D2644 ONLAY - PORCELN/CERAM - 4/MORE SURF $700.00 $160.00
D2650 INLAY RESIN COMPOSITE ONE SURFACE BY REPORT BY REPORT
D2651 INLAY RESIN COMPOSITE TWO SURFACES BY REPORT BY REPORT
D2652 INLAY RESIN COMPOSITE 3/> SURFACES $350.00 $262.00
D2662 ONLAY-RSN COMPOS COMPOS/RSN-2 SURF $124.00 $85.00
D2663 ONLAY-RSN COMPOS COMPOS/RSN-3 SURF BY REPORT BY REPORT
D2664 ONLAY RESIN COMPOSITE 4/> SURFACES BY REPORT BY REPORT
D2710 CROWN - RESIN-BASED COMPOSITE $361.00 $271.00
D2712 CROWN - 3/4 RESIN-BASED COMPOSITE $273.00 $205.00
D2720 CROWN - RESIN WITH HIGH NOBLE METAL $376.00 $160.00
D2721 CROWN - RESIN PREDOM BASE METAL $309.00 $232.00
D2722 CROWN - RESIN WITH NOBLE METAL $309.00 $232.00
D2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE $618.00 $400.00
D2750 CROWN - PORCELN FUSED HI NOBLE METL $700.00 $400.00
D2751 CROWN-PORCELN FUSD PREDOM BASE METL $618.00 $400.00
D2752 CROWN - PORCELAIN FUSED NOBLE METAL $618.00 $400.00
D2780 CROWN - 3/4 CAST HIGH NOBLE METAL $618.00 $400.00
D2781 CROWN - 3/4 CAST PREDOM BASE METL $567.00 $160.00
D2782 CROWN - 3/4 CAST NOBLE METAL $567.00 $160.00
D2783 CROWN - 3/4 PORCELAIN/CERAMIC $618.00 $400.00
D2790 CROWN - FULL CAST HIGH NOBLE METAL $618.00 $400.00
D2791 CROWN - FULL CAST PREDOM BASE METL $567.00 $160.00
D2792 CROWN - FULL CAST NOBLE METAL $618.00 $160.00
D2794 CROWN TITANIUM NOT COVERED NOT COVERED
D2799 PROV CROWN-TX/CMPL DX B4 FINAL IMP NOT COVERED NOT COVERED
D2910 RECEMENT INLAY ONLAY/PART COV REST $57.00 $17.00
D2915 RECEMENT CAST/PREFAB POST & CORE $57.00 $43.00
D2920 RECEMENT CROWN $57.00 $36.00
D2921 REATTCH TOOTH FRAG INCISL EDGE/CUSP NOT COVERED NOT COVERED
D2929 PREFAB PORC/CERAMC CROWN-PRIM TOOTH NOT COVERED NOT COVERED
D2930 PRFABR STAINLESS STEEL CROWN-PRIM $155.00 $100.00
D2931 PRFABR STAINLESS STEEL CROWN-PERM $181.00 $125.00
D2932 PREFABRICATED RESIN CROWN $186.00 $137.00
D2933 PRFABR STNLSS STEEL CROWN RSN WNDOW $206.00 $150.00
D2934 PREFB ESTHET COAT STNLSS STEEL CRWN NOT COVERED NOT COVERED
D2940 PROTECTIVE RESTORATION NOT COVERED NOT COVERED
D2941 INTRIM TX RESTORATION-PRIM DENTITN NOT COVERED NOT COVERED
D2949 RESTORATIV FOUNDATN INDIR RESTORATN NOT COVERED NOT COVERED
D2950 CORE BUILDUP INCL PINS WHEN REQUIRE $145.00 $83.00
D2951 PIN RETN - PER TOOTH ADDITION REST $37.00 $10.00
D2952 POST & CORE ADD CROWN INDIRECT FAB $232.00 $117.00
D2953 EA ADD INDIRECT FAB POST SAME TOOTH NOT COVERED NOT COVERED
D2954 PREFABR POST&CORE ADDITION CROWN $186.00 $125.00
D2955 POST REMOVAL NOT COVERED NOT COVERED
D2957 EA ADD PREFABR POST - SAME TOOTH NOT COVERED NOT COVERED
D2960 LABIAL VENEER RESIN LAM- CHAIRSIDE $258.00 $90.00
D2961 LABIAL VENEER - LABORATORY $515.00 $135.00
D2962 LABIAL VENEER - LABORATORY $567.00 $375.00
D2970 TEMPORARY CROWN FRACTURED TOOTH NOT COVERED NOT COVERED
D2971 ADD PROC NEW CROWN XST PART DENTURE NOT COVERED NOT COVERED
D2975 COPING NOT COVERED NOT COVERED
D2980 CROWN REPR NEC RESTORATV MATL FAIL $83.00 $65.00
D2981 INLAY REPR NEC RESTORATV MATL FAIL BY REPORT BY REPORT
D2982 ONLAY REPR NEC RESTORATV MATL FAIL BY REPORT BY REPORT
D2983 VENEER REPR NEC RESTORATV MATL FAIL BY REPORT BY REPORT
D2990 RESIN INFIL INCIPIENT SMTH SURF LES NOT COVERED NOT COVERED
D2999 UNSPEC RESTORATIVE PROC BY REPORT NOT COVERED NOT COVERED
D3110 PULP CAP - DIRECT NOT COVERED NOT COVERED
D3120 PULP CAP - INDIRECT NOT COVERED NOT COVERED
D3220 TX PULPOT-CORONL DENTNOCEMENTL JUNC $98.00 $63.00
D3221 PULPAL DEBRID PRIMARY&PERM TEETH $64.00 $50.00
D3222 PART PULPOTMY APEXOGNEIS PERM TOOTH BY REPORT BY REPORT
D3230 PULPAL THERAPY - ANT PRIMARY TOOTH $52.00 $10.00
D3240 PULPAL THERAPY - POST PRIMARY TOOTH $52.00 $10.00
D3310 ENDODONTIC THERAPY ANTERIOR TOOTH $450.00 $275.00
D3320 ENDODONTIC THERAPY BICUSPID TOOTH $550.00 $330.00
D3330 ENODODONTIC THERAPY MOLAR $618.00 $400.00
D3331 TX RC OBSTRUCTION; NON-SURG ACCESS $163.00 $80.00
D3332 INCMPL ENDO TX;INOP UNRSTR/FX TOOTH $129.00 $85.00
D3333 INTRL ROOT REPAIR PERFORATION DEFEC BY REPORT BY REPORT
D3346 RETX PREVIOUS RC THERAPY - ANTERIOR $412.00 $275.00
D3347 RETX PREVIOUS RC THERAPY - BICUSPID $515.00 $330.00
D3348 RETX PREVIOUS RC THERAPY - MOLAR $618.00 $400.00
D3351 APEX/RECALCIFICATION INITIAL VISIT $140.00 $25.00
D3352 APEX/RECALCIFICATN INTRM MED REPLAC NOT COVERED NOT COVERED
D3353 APEXIFICAT/RECALCIFICAT-FINAL VISIT NOT COVERED NOT COVERED
D3355 PULPAL REGENERATION - INITIAL VISIT NOT COVERED NOT COVERED
D3356 PULPAL REGENERATION - MED REPLACMNT NOT COVERED NOT COVERED
D3357 PULPAL REGENERATION - COMPLETION TX NOT COVERED NOT COVERED
D3410 APICOECTOMY - ANTERIOR $438.00 $110.00
D3421 APICOECTOMY - BICUSPID FIRST ROOT $464.00 $125.00
D3425 APICOECTOMY - MOLAR FIRST ROOT $541.00 $150.00
D3426 APICOECTOMY EACH ADDITIONAL ROOT $88.00 $30.00
D3427 PERIRADICULAR SURG W/O APICOECTOMY BY REPORT BY REPORT
D3428 BONE GRAFT PERIRADICULR SURG 1 SITE $250.00 $150.00
D3429 BONE GRAFT PERIRADICULR SURG EA ADD BY REPORT BY REPORT
D3430 RETROGRADE FILLING - PER ROOT $150.00 $40.00
D3431 BIOL MATL TSS REGEN PERIRADICLR SRG BY REPORT BY REPORT
D3432 GUIDE TISS REGEN PERIRADICULAR SURG $361.00 $270.00
D3450 ROOT AMPUTATION - PER ROOT $222.00 $40.00
D3460 ENDODONTIC ENDOSSEOUS IMPLANT BY REPORT BY REPORT
D3470 INTENTIONAL REIMPLANTATION BY REPORT BY REPORT
D3910 SURG PROC ISOLAT TOOTH W/RUBBER DAM NOT COVERED NOT COVERED
D3920 HEMISECTION NOT INCL RC THERAPY $206.00 $40.00
D3950 CANAL PREP&FIT PREFORMED DOWEL/POST NOT COVERED NOT COVERED
D3999 UNSPEC ENDODONTIC PROCEDURE REPORT NOT COVERED NOT COVERED
D4210 GINGIVECT/PLSTY 4/>CNTIG TEETH QUAD $320.00 $80.00
D4211 GINGIVECT/PLSTY 1-3CNTIG TEETH QUAD $248.00 $186.00
D4212 GING/GINGIVOPLASTY RES PROC-TOOTH $248.00 $180.00
D4230 ANAT CROWN EXP 4/> CONT TEETH QUAD BY REPORT BY REPORT
D4231 ANAT CROWN EXP 1- 3 TEETH PER QUAD BY REPORT BY REPORT
D4240 GINGL FLP 4/>CNTIG/TOOTH BOUND QUAD $340.00 $150.00
D4241 GINGL FLP 1-3 CNTIG/TOOTH BND QUAD $268.00 $110.00
D4245 APICALLY POSITIONED FLAP $361.00 $200.00
D4249 CLIN CROWN LEN - HARD TISSUE $232.00 $150.00
D4260 OSSEOUS SURG 4/> CNTIG TEETH QUAD $670.00 $450.00
D4261 OSSEOUS SURG 1-3 CNTIG TEETH QUAD $412.00 $200.00
D4263 BN REPL GR-RET NAT TT-1ST SITE QUAD $258.00 $150.00
D4264 BRG-RET NAT TOOTH-EA ADD SITE QUAD $206.00 $100.00
D4265 BIO MATL AID SFT&OSSEOUS TISS REGEN NOT COVERED NOT COVERED
D4266 GUID TISS REGEN-RESORB BARRIER-SITE $361.00 $270.00
D4267 GUID TISS REGEN-NONRESORB BARRIER $361.00 $270.00
D4268 SURGICAL REVISION PROC PER TOOTH $309.00 $232.00
D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE $392.00 $300.00
D4271 FREE SOFT TISSUE GRAFT PROCEDURE $500.00 $300.00
D4273 AUTOGEN CONNECTIVE TISS GRAFT PROC $392.00 $300.00
D4274 MESIAL/DISTAL WEDGE PROC 1 TOOTH $258.00 $200.00
D4275 NON-AUTOGENOUS CONNECTIVE TISS GRFT $515.00 $300.00
D4276 COMB CNCTIV TISS&DBL PED GRFT TOOTH BY REPORT BY REPORT
D4277 FREE SFT TSS GFT 1ST T/EDNTULOUS T $515.00 $300.00
D4278 FREE ST GFT EA CNTG T/EDNT T SAME S $258.00 $232.00
D4283 AUTOGEN CONNECTIVE TISS GRAFT PROC $289.00 $200.00
D4285 NON-AUTOGEN CNCT TISSUE GRAFT PROC $155.00 $116.00
D4320 PROVISIONAL SPLINTING-INTRACORONAL $155.00 $116.00
D4321 PROVISIONAL SPLINTING EXTRACORONAL $155.00 $116.00
D4341 PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUAD $165.00 $104.00
D4342 PRDONTAL SCAL&ROOT PLAN 1-3 TEETH $120.00 $60.00
D4346 SCALING PRES GEN MOD/SEV GING INF $174.00 $130.00
D4355 FULL MOUTH DEBRID COMP EVAL&DX $140.00 $100.00
D4381 LOC DEL ANTIM DZ CRVICUL TISS-TOOTH NOT COVERED NOT COVERED
D4910 PERIODONTAL MAINTENANCE $83.00 $53.00
D4920 UNSCHEDULED DRESSING CHANGE $26.00 $8.00
D4921 GINGIVAL IRRIGATION - PER QUADRANT $26.00 $20.00
D4999 UNSPEC PERIODONTAL PROCEDURE REPORT BY REPORT BY REPORT
D5110 COMPLETE DENTURE - MAXILLARY $927.00 $445.00
D5120 COMPLETE DENTURE - MANDIBULAR $927.00 $445.00
D5130 IMMEDIATE DENTURE - MAXILLARY $927.00 $445.00
D5140 IMMEDIATE DENTURE - MANDIBULAR $927.00 $445.00
D5211 MAXILLARY PARTIAL DENTUR RESIN BASE $800.00 $175.00
D5212 MANDIB PARTIAL DENTURE RESIN BASE $800.00 $175.00
D5213 MAX PART DENTUR-CAST METL W/RSN $1,110.00 $578.00
D5214 MAND PART DENTUR- CAST METL W/RSN $1,110.00 $578.00
D5221 IMMED MAXIL PART DENTURE-RESIN BASE $800.00 $600.00
D5222 IMMED MAND PART DENTURE-RESIN BASE $800.00 $600.00
D5223 IMMED MAXIL PRT DENTUR-CAST METL FW $1,100.00 $578.00
D5224 IMMED MAND PRT DENTURE-CAST METL FW $1,100.00 $578.00
D5225 MAXILLARY PARTIAL DENTURE FLEX BASE $1,110.00 $578.00
D5226 MANDIBULAR PART DENTURE FLEX BASE $1,110.00 $578.00
D5281 REMV UNI PART DENTUR-1 PC CAST METL $474.00 $345.00
D5410 ADJUST COMPLETE DENTURE - MAXILLARY $47.00 $17.00
D5411 ADJUST COMPLETE DENTUR - MANDIBULAR $47.00 $17.00
D5421 ADJUST PARTIAL DENTURE - MAXILLARY $47.00 $17.00
D5422 ADJUST PARTIAL DENTURE - MANDIBULAR $47.00 $17.00
D5510 REPAIR BROKEN COMPLETE DENTURE BASE $103.00 $28.00
D5511 REPAIR BROKEN COMPLETE DENTURE BASE MANDIBULAR $103.00 $28.00
D5512 REPAIR BROKEN COMPLETE DENTURE BASE MAXILLARY $103.00 $28.00
D5520 REPL MISS/BROKEN TEETH-CMPL DENTUR $85.00 $28.00
D5610 REPAIR RESIN DENTURE BASE $103.00 $28.00
D5611 REPAIR RESIN PARTIAL DENTURE BASE MANDIBULAR $103.00 $28.00
D5612 REPAIR RESIN PARTIAL DENTURE BASE MAXILLARY $103.00 $28.00
D5620 REPAIR CAST FRAMEWORK $103.00 $28.00
D5621 REPAIR CAST PARTIAL FRAMEWORK MANDIBULAR $103.00 $28.00
D5622 REPAIR CAST PARTIAL FRAMEWORK MAXILLARY $103.00 $28.00
D5630 REPR/REPLCE BROKEN CLASP-PER TOOTH $129.00 $32.00
D5640 REPLACE BROKEN TEETH - PER TOOTH $88.00 $40.00
D5650 ADD TOOTH EXISTING PARTIAL DENTURE $103.00 $63.00
D5660 ADD CLASP XST PRT DENTURE-PER TOOTH $134.00 $50.00
D5670 REPL ALL TEETH&ACRYLC FRMEWRK MAX $36.00 $14.00
D5671 REPL ALL TEETH&ACRYLC FRMEWRK MAND $36.00 $14.00
D5710 REBASE COMPLETE MAXILLARY DENTURE $309.00 $105.00
D5711 REBASE COMPLETE MANDIBULAR DENTURE $309.00 $105.00
D5720 REBASE MAXILLARY PARTIAL DENTURE $309.00 $105.00
D5721 REBASE MANDIBULAR PARTIAL DENTURE $309.00 $105.00
D5730 RELINE CMPL MAXIL DENTURE CHAIRSIDE $196.00 $50.00
D5731 RELINE COMPLETE MANDIBULAR DENTURE $196.00 $50.00
D5740 RELINE MAXIL PART DENTURE CHAIRSIDE $186.00 $50.00
D5741 RELINE MAND PART DENTURE CHAIRSIDE $186.00 $50.00
D5750 RELINE CMPL MAXIL DENTURE LAB $258.00 $100.00
D5751 RELINE CMPL MAND DENTRUE LABORATORY $258.00 $100.00
D5760 RELINE MAXIL PART DENTURE LAB $258.00 $100.00
D5761 RELINE MAND PART DENTURE LABORATORY $258.00 $100.00
D5810 INTERIM COMPLETE DENTURE MAXILLARY NOT COVERED NOT COVERED
D5811 INTERIM COMPLETE DENTURE MANDIBULAR NOT COVERED NOT COVERED
D5820 INTERIM PARTIAL DENTURE MAXILLARY $335.00 $103.00
D5821 INTERIM PARTIAL DENTURE MANDIBULAR $335.00 $103.00
D5850 TISSUE CONDITIONING MAXILLARY $93.00 $21.00
D5851 TISSUE CONDITIONING MANDIBULAR $93.00 $21.00
D5860 OVERDENTURE - COMPLETE BY REPORT $530.00 $210.00
D5861 OVERDENTURE - PARTIAL BY REPORT $580.00 $240.00
D5862 PRECISION ATTACHMENT BY REPORT $103.00 $75.00
D5863 OVERDENTURE - COMPLETE MAXILLARY $546.00 $409.00
D5864 OVERDENTURE - PARTIAL MAXILLARY $598.00 $448.00
D5865 OVERDENTURE - COMPLETE MANDIBULAR $1,236.00 $927.00
D5866 OVERDENTURE - PARTIAL MANDIBULAR $927.00 $695.00
D5867 REPL PART SEMI-PRCISN/PRCISN ATTCH $103.00 $77.00
D5875 MOD REMV PROSTH FOLLOW IMPL SURG $268.00 $201.00
D5899 UNS REMV PROSTHODONTIC PROC RPT BY REPORT BY REPORT
D5911 FACIAL MOULAGE SECTIONAL BY REPORT BY REPORT
D5912 FACIAL MOULAGE COMPLETE BY REPORT BY REPORT
D5913 NASAL PROSTHESIS BY REPORT BY REPORT
D5914 AURICULAR PROSTHESIS BY REPORT BY REPORT
D5915 ORBITAL PROSTHESIS BY REPORT BY REPORT
D5916 OCULAR PROSTHESIS BY REPORT BY REPORT
D5919 FACIAL PROSTHESIS BY REPORT BY REPORT
D5922 NASAL SEPTAL PROSTHESIS BY REPORT BY REPORT
D5923 OCULAR PROSTHESIS INTERIM BY REPORT BY REPORT
D5924 CRANIAL PROSTHESIS BY REPORT BY REPORT
D5925 FACIAL AUGMENTATION IMPLANT PROSTH BY REPORT BY REPORT
D5926 NASAL PROSTHESIS REPLACEMENT BY REPORT BY REPORT
D5927 AURICULAR PROSTHESIS REPLACEMENT BY REPORT BY REPORT
D5928 ORBITAL PROSTHESIS REPLACEMENT BY REPORT BY REPORT
D5929 FACIAL PROSTHESIS REPLACEMENT BY REPORT BY REPORT
D5931 OBTURATOR PROSTHESIS SURGICAL BY REPORT BY REPORT
D5932 OBTURATOR PROSTHESIS DEFINITIVE BY REPORT BY REPORT
D5933 OBTURATOR PROSTHESIS MODIFICATION BY REPORT BY REPORT
D5934 MANDIB RESECT PROSTH W/GUIDE FLANGE BY REPORT BY REPORT
D5935 MANDIB RES PROSTH W/O GUIDE FLANGE BY REPORT BY REPORT
D5936 OBTURATOR/PROSTHESIS INTERIM BY REPORT BY REPORT
D5937 TRISMUS APPLIANCE NOT FOR TMD TX BY REPORT BY REPORT
D5951 FEEDING AID BY REPORT BY REPORT
D5952 SPEECH AID PROSTHESIS PEDIATRIC BY REPORT BY REPORT
D5953 SPEECH AID PROSTHESIS ADULT BY REPORT BY REPORT
D5954 PALATAL AUGMENTATION PROSTHESIS BY REPORT BY REPORT
D5955 PALATAL LIFT PROSTHESIS DEFINITIVE BY REPORT BY REPORT
D5958 PALATAL LIFT PROSTHESIS INTERIM BY REPORT BY REPORT
D5959 PALATAL LIFT PROSTH MODIFICATION BY REPORT BY REPORT
D5960 SPEECH AID PROSTHESIS MODIFICATION BY REPORT BY REPORT
D5982 SURGICAL STENT BY REPORT BY REPORT
D5983 RADIATION CARRIER BY REPORT BY REPORT
D5984 RADIATION SHIELD BY REPORT BY REPORT
D5985 RADIATION CONE LOCATOR BY REPORT BY REPORT
D5986 FLUORIDE GEL CARRIER BY REPORT BY REPORT
D5987 COMMISSURE SPLINT BY REPORT BY REPORT
D5988 SURGICAL SPLINT BY REPORT BY REPORT
D5991 VESICULOBULLOUS DZ MEDICAMENT CARR BY REPORT BY REPORT
D5992 ADJ MAXILLOFACIAL PROSTH APPL BR BY REPORT BY REPORT
D5993 MAINT CLEAN MFP OTH THAN REQ ADJ BY REPORT BY REPORT
D5994 PERIODONTAL MED CARRIER LAB PROCESS BY REPORT BY REPORT
D5999 UNS MAXILLOFACIAL PROSTH BY REPORT BY REPORT BY REPORT
D6010 SURG PLCMT IMPL BODY: ENDOSTEAL $1,180.00 $960.00
D6011 SECOND STAGE IMPLANT SURGERY NOT COVERED NOT COVERED
D6012 SURG PLCMT INTERIM IMPL PROS: ENDOS NOT COVERED NOT COVERED
D6013 SURGICAL PLACEMENT OF MINI IMPLANT $927.00 $695.00
D6040 SURG PLACEMENT: EPOSTEAL IMPLANT BY REPORT BY REPORT
D6050 SURG PLACEMENT: TRANSOSTEAL IMPLANT BY REPORT BY REPORT
D6051 INTERIM ABUTMENT NOT COVERED NOT COVERED
D6052 SEMI-PRECISION ATTACHMENT ABUTMENT BY REPORT BY REPORT
D6053 IMPL/ABUT SUPP REMV DENTUR CMPL EDNTULS ARCH $1,200.00 $900.00
D6054 IMPL/ABUT SUPP REMV DENTUR PART EDNTULS ARCH BY REPORT BY REPORT
D6055 CONNECTING BAR IMPLANT/ABUT SUPPORT $309.00 $300.00
D6056 PREFAB ABUTMENT-INCL MOD & PLCMNT $438.00 $320.00
D6057 CUSTOM FAB ABUTMENT-INCL PLACEMENT $438.00 $320.00
D6058 ABUT SUPP PORCELN/CERAMIC CROWN $618.00 $400.00
D6059 ABUT PORCLN TO MTL CRWN HI NOBL MTL $618.00 $400.00
D6060 ABUT PORCLN TO METL CROWN BASE METL $618.00 $400.00
D6061 ABUT PORCLN TO MTL CROWN NOBLE MTL $618.00 $400.00
D6062 ABUT SUPP CAST MTL CRWN HI NOBL MTL $618.00 $400.00
D6063 ABUT SUPP CAST METL CROWN BASE METL $618.00 $400.00
D6064 ABUT SUPP CAST METL CROWN NOBL METL $618.00 $355.00
D6065 IMPLANT SUPP PORCELN/CERAMIC CROWN $618.00 $400.00
D6066 IMPL SUPP PORCELN FUSED METAL CROWN $618.00 $400.00
D6067 IMPLANT SUPPORTED METAL CROWN $618.00 $400.00
D6068 ABUT SUPP RETAIN PORCELN/CERAM FPD $618.00 $400.00
D6069 ABUT RETN PORCLN MTL FPD HI NOBL MT $618.00 $400.00
D6070 ABUT RETN PORCLN METL FPD BASE METL BY REPORT BY REPORT
D6071 ABUT SUPP RETN PORCLN FUSD METL FPD $618.00 BY REPORT
D6072 ABUT SUPP RETAIN CAST METAL FPD BY REPORT BY REPORT
D6073 ABUT RETN CAST METL FPD BASE METL BY REPORT BY REPORT
D6074 ABUT RETN CAST METL FPD NOBL METL BY REPORT BY REPORT
D6075 IMPLANT SUPP RETAIN CERAMIC FPD BY REPORT BY REPORT
D6076 IMPL SUPP RETN PORCLN FUSD METL FPD $618.00 $463.00
D6077 IMPLANT SUPP RETAIN CAST METAL FPD BY REPORT BY REPORT
D6078 IMPLANT ABUTMENT BY REPORT BY REPORT
D6079 IMPLANT ABUTMENT BY REPORT BY REPORT
D6080 IMPL MAINT PROC REMV REINSRT CLEAN $57.00 $39.00
D6081 SCAL & DEBR PRES INFL/MUCOSIT1 IMPL $165.00 $104.00
D6085 PROVISIONAL IMPLANT CROWN BY REPORT BY REPORT
D6090 REPAIR IMPL SUPP PROSTH BY REPORT BY REPORT BY REPORT
D6091 REPL IMPL/ABUT PROS PER ATTACHMENT $103.00 $77.00
D6092 RECEMENT IMPL/ABUT SUPPORTED CROWN $57.00 $43.00
D6093 RECEMENT IMPL/ABUT FIX PART DENTURE $57.00 $43.00
D6094 ABUTMENT SUPPORTED CROWN TITANIUM $57.00 $43.00
D6095 REPAIR IMPLANT ABUTMENT BY REPORT BY REPORT BY REPORT
D6099 IMPL SUPP RETAINR FPD-PORCE FUSED NOBLE ALLS $618.00 $463.00
D6100 IMPLANT REMOVAL BY REPORT $289.00 $188.00
D6101 DEBR PRIIMPL DEF CLN EXPSD IMPL FLP $140.00 $100.00
D6102 DEBR&OSS CNTR PRIIMPL DEF;CLN SURF BY REPORT BY REPORT
D6103 BONE GRAFT REPAIR PERI-IMPL DEFECT $351.00 $255.00
D6104 BONE GRAFT TIME IMPLANT PLACEMENT $258.00 $150.00
D6110 IMPL/ABUT SUPP RMV D EDENT ARCH-MAX $1,236.00 $927.00
D6111 IMPL/ABUT SUPP RMV D EDENT ARCH-MND $1,236.00 $927.00
D6112 IMPL/ABUT SUP RMV D PR EDNT ARCH-MX $618.00 $463.00
D6113 IMPL/ABUT SP RMV D PR EDNT ARCH-MND $618.00 $463.00
D6114 IMPL/ABUT SP FIXED D EDENT ARCH-MAX $1,236.00 $927.00
D6115 IMPL/ABUT SUP FIXD D EDENT ARCH-MND $1,236.00 $927.00
D6116 IMPL/ABUT SUP F D PR EDENT ARCH-MAX $618.00 $463.00
D6117 IMPL/ABUT SP FIXD D PR EDENT ARCH-M $618.00 $463.00
D6118 IMPL/ABUT SPTD INTRM FIX DENTUR EDENT ARCH-MAND BY REPORT BY REPORT
D6119 IMPL/ABUT SPTD INT FIX DENTUR EDENT ARCH-MAX BY REPORT BY REPORT
D6190 RADIOGRAPHIC/SURG IMPLANT INDX RPT $155.00 $117.00
D6194 ABUTMENT SUPP RETAINR CROWN FOR FPD $618.00 $463.00
D6199 UNSPEC IMPLANT PROCEDURE BY REPORT $103.00 $75.00
D6205 PONTIC INDIRECT RESIN BASED COMPOS $424.00 $318.00
D6210 PONTIC - CAST HIGH NOBLE METAL $650.00 $160.00
D6211 PONTIC - CAST PREDOM BASE METAL $550.00 $160.00
D6212 PONTIC - CAST NOBLE METAL $598.00 $160.00
D6214 PONTIC TITANIUM NOT COVERED NOT COVERED
D6240 PONTIC-PORCELN FUSED HI NOBLE METL $618.00 $370.00
D6241 PONTIC-PORCLN FUSD PREDOM BASE METL $527.00 $160.00
D6242 PONTIC - PORCELN FUSED NOBLE METAL $513.00 $160.00
D6245 PONTIC - PORCELAIN/CERAMIC $618.00 $370.00
D6250 PONTIC - RESIN W/HIGH NOBLE METAL $515.00 $386.00
D6251 PONTIC RESIN W/PREDOM BASE METAL $424.00 $228.00
D6252 PONTIC RESIN W/NOBLE METAL $424.00 $228.00
D6253 PRVS PONTIC-TX/CMPL DX NEC B4 F IMP NOT COVERED NOT COVERED
D6545 RETN-CAST METL RSN BOND FIX PROSTH $370.00 $299.00
D6548 RETN-PORCELN/CERAM RSN BOND PROSTH BY REPORT BY REPORT
D6549 RETAINER - RESIN BONDED FIXED PROS BY REPORT BY REPORT
D6600 RETAINER INLAY-PORCELN/CERAM 2 SURF BY REPORT BY REPORT
D6601 RETAINER INLAY-PORC/CERAM 3/MOR SRF BY REPORT BY REPORT
D6602 RET INLAY-CAST HI NOBLE METL 2 SURF BY REPORT BY REPORT
D6603 RET INLA-CST HI NOBL MTL 3/MORE SRF BY REPORT BY REPORT
D6604 RET INLAY-CAST PDMT BASE METL 2 SRF BY REPORT BY REPORT
D6605 RET INLA-CST PDMT BSE MTL 3/MOR SRF BY REPORT BY REPORT
D6606 RETAIN INLAY-CAST NOBLE METL 2 SURF BY REPORT BY REPORT
D6607 RET INLAY-CAST NOBLE METL 3/MRE SRF BY REPORT BY REPORT
D6608 RETAINER ONLAY-PORCELN/CERAM 2 SURF BY REPORT BY REPORT
D6609 RETAINR ONLAY-PORC/CERAM 3/MORE SRF BY REPORT BY REPORT
D6610 RET ONLAY-CAST HI NOBLE METL 2 SURF BY REPORT BY REPORT
D6611 RET ON-CST HI NOBLE METL 3/MORE SRF BY REPORT BY REPORT
D6612 ONLAY-CAST PREDOM BASE METL 2 SURF BY REPORT BY REPORT
D6613 RET ON-CST PDMT BSE METL 3/MORE SRF BY REPORT BY REPORT
D6614 RET ONLAY-CAST NOBLE METAL 2 SURF BY REPORT BY REPORT
D6615 RET ONLAY-CST NOBLE METL 3/MORE SRF BY REPORT BY REPORT
D6624 RETAINER INLAY - TITANIUM BY REPORT BY REPORT
D6634 RETAINER ONLAY - TITANIUM BY REPORT BY REPORT
D6710 RET CROWN-INDIR RESIN BASED COMPOS BY REPORT BY REPORT
D6720 RETAINER CROWN-RESIN HI NOBLE METAL $376.00 $360.00
D6721 RETAINER CROWN-RESIN PDMT BASE METL BY REPORT BY REPORT
D6722 RETAINER CROWN-RESIN W/NOBLE METAL BY REPORT BY REPORT
D6740 RETAINER CROWN - PORCELAIN/CERAMIC $618.00 $400.00
D6750 RET CROWN-PORC FUSED HI NOBLE METL $618.00 $400.00
D6751 RET CROWN-PORC FUSED PDMT BASE METL $618.00 $400.00
D6752 RETNR CRWN-PORCELN FUSD NOBLE METAL $618.00 $400.00
D6780 RETNER CROWN-3/4 CAST HI NOBLE METL $618.00 $400.00
D6781 RETNR CRWN-3/4 CAST PDMT BASE METAL BY REPORT BY REPORT
D6782 RETAINER CROWN-3/4 CAST NOBLE METAL BY REPORT BY REPORT
D6783 RETAINER CROWN-3/4 PORCELAIN/CERAMC BY REPORT BY REPORT
D6790 RETNR CRWN-FULL CAST HI NOBLE METAL $618.00 $400.00
D6791 RETNR CRWN-FULL CAST PDMT BASE METL $567.00 $400.00
D6792 RETAINER CROWN-FULL CAST NOBLE METL $618.00 $400.00
D6793 PRVS RET CRWN-TX/CMPL DX B4 FNL IMP BY REPORT BY REPORT
D6794 RETAINER CROWN - TITANIUM BY REPORT BY REPORT
D6920 CONNECTOR BAR BY REPORT BY REPORT
D6930 RECEMENT FIXED PARTIAL DENTURE $83.00 $25.00
D6940 STRESS BREAKER $124.00 $30.00
D6950 PRECISION ATTACHMENT $103.00 $75.00
D6970 RETAINER CROWN PORCELAIN $100.00 $50.00
D6972 PREFAB ABUTMENT-INCL MOD & PLCMNT BY REPORT BY REPORT
D6973 CORE BUILDUP INCL PINS WHEN REQUIRE $251.00 $188.00
D6975 COPING BY REPORT BY REPORT
D6976 EACH ADDITIONAL POST BY REPORT BY REPORT
D6977 EACH PREFABRICATED POST BY REPORT BY REPORT
D6980 FXD PRT DNTR REPR NEC RSTRTV MTL FL $364.00 $80.00
D6985 PEDIATRIC PARTIAL DENTURE FIXED NOT COVERED NOT COVERED
D6999 UNSPEC FIX PROSTHODONTIC PROC BR $100.00 $75.00
D7111 XTRCT CORONL RMNNTS DECIDUOUS TOOTH $67.00 $52.00
D7140 EXTRAC ERUPTED TOOTH/EXPOSED ROOT $120.00 $52.00
D7210 EXTN ERU TT RQR REMV BONE &/SECT TT $145.00 $96.00
D7220 REMOVAL IMPACT TOOTH - SOFT TISSUE $200.00 $125.00
D7230 REMOVAL IMPACT TOOTH - PARTLY BONY $230.00 $151.00
D7240 REMOVAL IMPACTED TOOTH - CMPL BONY $260.00 $177.00
D7241 REMV IMP TOOTH-CMPL BNY W/SURG COMP $284.00 $207.00
D7250 REMOVAL OF RESIDUAL TOOTH ROOTS $175.00 $132.00
D7251 CORONECTOMY PARTIAL TOOTH REMOVAL $425.00 $319.00
D7260 OROANTRAL FISTULA CLOSURE $309.00 $232.00
D7261 PRIMARY CLOSURE SINUS PERFORATION $309.00 $232.00
D7270 TOOTH REIMPL&/STBL ACC DISPLCD $309.00 $40.00
D7272 TOOTH TRANSPLANTATION $309.00 $85.00
D7280 EXPOSURE OF AN UNERUPTED TOOTH $258.00 $194.00
D7282 MOBILZ ERUPT/MALPSTN TOOTH AID ERUP $760.00 $456.00
D7283 PLCMT DEVC FACL ERUPT IMPACT TOOTH $200.00 $150.00
D7285 BIOPSY OF ORAL TISSUE HARD $149.00 $112.00
D7286 BIOPSY OF ORAL TISSUE SOFT $134.00 $98.00
D7287 EXFOLIATIVE CYTOLOG SAMPLE CLCTION BY REPORT BY REPORT
D7288 BRUSH BX TRANSEPITH SAMPLE CLCTION BY REPORT BY REPORT
D7290 SURGICAL REPOSITIONING OF TEETH BY REPORT BY REPORT
D7291 TRNSSEPTL/SUPRA CRESTAL FIBEROT BR BY REPORT BY REPORT
D7292 PLCMT T ANC D SCREW RETN RQR FLAP; BY REPORT BY REPORT
D7293 PLCMT TMP ANC D RQR FLAP;INC D REMV BY REPORT BY REPORT
D7294 PLCMT T ANC D W/O FLAP; INC D REMV BY REPORT BY REPORT
D7295 HARVEST BONE USE AUTOGEN GRAFT PROC BY REPORT BY REPORT
D7296 CORTICOTOMY-ONE TO THREE TEETH/TOOTH SP PER QUAD BY REPORT BY REPORT
D7297 CORTICOTOMY-FOUR OR MORE TEETH/TOOTH SP PER QUAD BY REPORT BY REPORT
D7310 ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE $155.00 $32.00
D7311 ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETH $85.00 $25.00
D7320 ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC $176.00 $36.00
D7321 ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETH $155.00 $116.00
D7340 VESTIBULOPLASTY RIDGE EXT SEC EPITH BY REPORT BY REPORT
D7350 VESTBULPLSTY RIDGE EXT SFT TISS GFT $206.00 $90.00
D7410 EXCISION BENIGN LESION TO 1.25 CM $124.00 $35.00
D7411 EXCISION OF BENIGN LESION > 1.25 CM $198.00 $50.00
D7412 EXCISION BENIGN LESION COMPLICATED $700.00 $525.00
D7413 EXCISION MALIG LESION UP 1.25 CM BY REPORT BY REPORT
D7414 EXCISION MALIGNANT LESION > 1.25 CM BY REPORT BY REPORT
D7415 EXCISION MALIG LESION COMPLICATED BY REPORT BY REPORT
D7440 EXC MALIG TUMR - UP 1.25 CM SEE CPT BY REPORT BY REPORT
D7441 EXC MALIG TUMOR/LES > 1.25CM BY REPORT BY REPORT
D7450 REMV BEN ODONTOGNIC TUMR-T0 1.25 CM $217.00 $40.00
D7451 REMV BEN ODONTOGNIC TUMR >1.25 CM $268.00 $90.00
D7460 REMV BEN NONODONTGN TUMR-TO 1.25 CM $222.00 $40.00
D7461 REMV BEN NONODONTOGNIC TUMR>1.25 CM $268.00 $90.00
D7465 DESTRUCT LES PHYS/CHEM METH BY RPRT BY REPORT BY REPORT
D7471 REMOVAL OF LATERAL EXOSTOSIS $279.00 $55.00
D7472 REMOVAL OF TORUS PALATINUS $618.00 $215.00
D7473 REMOVAL OF TORUS MANDIBULARIS $222.00 $166.00
D7485 REDUCTION OF OSSEOUS TUBEROSITY $222.00 $166.00
D7490 RADICAL RESECTION MAXLA OR MANDIBLE BY REPORT BY REPORT
D7510 I&D ABSCESS-INTRAORAL SOFT TISS $110.00 $18.00
D7511 I & D ABSC INTRAORAL SOFT TISS COMP $155.00 $30.00
D7520 I&D ABSC EXTRAORAL SOFT TISS $128.00 $23.00
D7521 I & D ABSC XTRAORAL SOFT TISS COMP BY REPORT BY REPORT
D7530 REMV FB MUCOS SKN/SUBQ ALVEOL TISS $155.00 $16.00
D7540 REMV REACT-PRODUC FB MUSCLOSKEL SYS BY REPORT BY REPORT
D7550 PART OSTEC/SEQECT REMV NON-VITAL BN $222.00 $100.00
D7560 MAXIL SINUSOT REMV TOOTH FRAG/FB $402.00 $95.00
D7610 MAXILLA-OPEN REDUCTION $1,002.00 $340.00
D7620 MAXILLA-CLOSED REDUCTION $836.00 $200.00
D7630 MANDIBLE-OPEN REDUCTION $1,002.00 $385.00
D7640 MANDIBLE-CLOSED REDUCTION $836.00 $230.00
D7650 MALAR&/ZYGO ARCH-OPEN REDUCTION $557.00 $240.00
D7660 MALAR&/ZYGO ARCH-CLOSED REDUCTION $351.00 $150.00
D7670 ALVEOLUS-CLS RDUC INC STABIL TEETH $307.00 $150.00
D7671 ALVEOLUS-OPN RDUC INCL STABIL TEETH BY REPORT BY REPORT
D7680 FCE BNS-COMP RDUC FIX&MX APPRCH BY REPORT BY REPORT
D7710 MAXILLA OPEN REDUCTION $938.00 $400.00
D7720 MAXILLA CLOSED REDUCTION $701.00 $300.00
D7730 MANDIBLE OPEN REDUCTION $938.00 $400.00
D7740 MANDIBLE CLOSED REDUCTION $670.00 $288.00
D7750 MALR&/ZYGOMATIC ARCH-OPEN RDUC $670.00 $288.00
D7760 MALAR&/ZYGO ARCH CLOSED REDUCTION $515.00 $144.00
D7770 ALVEOL - OPEN RDUC STBL TEETH BY REPORT BY REPORT
D7771 ALVEOL CLOS RDUC STBL TEETH BY REPORT BY REPORT
D7780 FCE BNS-COMP RDUC FIX & MX APPRCHES BY REPORT BY REPORT
D7810 OPEN REDUCTION OF DISLOCATION BY REPORT BY REPORT
D7820 CLOSED REDUCTION OF DISLOCATION $90.00 $67.00
D7830 MANIPULATION UNDER ANESTHESIA $90.00 $67.00
D7840 CONDYLECTOMY $680.00 $510.00
D7850 SURGICAL DISCECTOMY W/WO IMPLANT $680.00 $510.00
D7852 DISC REPAIR BY REPORT BY REPORT
D7854 SYNOVECTOMY BY REPORT BY REPORT
D7856 MYOTOMY BY REPORT BY REPORT
D7858 JOINT RECONSTRUCTION BY REPORT BY REPORT
D7860 ARTHROTOMY BY REPORT BY REPORT
D7865 ARTHROPLASTY BY REPORT BY REPORT
D7870 ARTHROCENTESIS BY REPORT BY REPORT
D7871 NON-ARTHROSCOPIC LYSIS AND LAVAGE BY REPORT BY REPORT
D7872 ARTHROSCOPY DIAGNOSIS W/WO BIOPSY BY REPORT BY REPORT
D7873 ARTHROSCOPY: LAVAGE & LYSIS OF ADH BY REPORT BY REPORT
D7874 ARTHROSCOPY: DISC REPOS & STBL BY REPORT BY REPORT
D7875 ARTHROSCOPY: SYNOVECTOMY BY REPORT BY REPORT
D7876 ARTHROSCOPY: DISCECTOMY BY REPORT BY REPORT
D7877 ARTHROSCOPY: DEBRIDEMENT BY REPORT BY REPORT
D7880 OCCLUSAL ORTHOTIC DEVICE BY REPORT BY REPORT BY REPORT
D7881 OCCLUSAL ORTHOTIC DEVICE ADJUSTMENT BY REPORT BY REPORT
D7899 UNSPECIFIED TMD THERAPY BY REPORT BY REPORT BY REPORT
D7910 SUTURE RECENT SMALL WOUNDS UP 5 CM $106.00 $79.00
D7911 COMPLICATED SUTURE UP TO 5CM BY REPORT BY REPORT
D7912 COMPLICATED SUTURE > 5 CM BY REPORT BY REPORT
D7920 SKIN GRAFT BY REPORT BY REPORT
D7921 COLLECT&APPLIC AUTO BLOOD CONC PROD $412.00 $250.00
D7940 OSTEOPLASTY - ORTHOGNATHIC DEFORM $938.00 $400.00
D7941 OSTEOTOMY - MANDIBULAR RAMI BY REPORT BY REPORT
D7943 OSTEOT-MAND RAMI BN GFT; OBTAIN GFT BY REPORT BY REPORT
D7944 OSTEOTOMY SEGMENTED OR SUBAPICAL BY REPORT BY REPORT
D7945 OSTEOTOMY-BODY OF MANDIBLE BY REPORT BY REPORT
D7946 LEFORT I MAXILLA TOTAL BY REPORT BY REPORT
D7947 LEFORT I MAXILLA SEGMENTED BY REPORT BY REPORT
D7948 LEFORT II/LEFORT III - W/O BONE GFT BY REPORT BY REPORT
D7949 LEFORT II/LEFORT III - W/BONE GRAFT BY REPORT BY REPORT
D7950 OSS OSTEOPERIOSTL CART GFT MAND/MAX $1,687.00 $1,265.00
D7951 SINUS AUG BONE/BONE SUBST LAT OPN $1,200.00 $900.00
D7952 SINUS AUGMENTATION VERTICAL APPR $1,200.00 $900.00
D7953 BONE REPLCMT GRAFT RIDGE PRES -SITE $250.00 $150.00
D7955 REPR MAXLOFACL SOFT&/HARD TISS DFCT BY REPORT BY REPORT
D7960 FRENULECTOMY SEP PROC NOT INCIDENTL $206.00 $155.00
D7961 BUCCAL / LABIAL FRENECTOMY (FRENULECTOMY) $206.00 $155.00
D7962 LINGUAL FRENECTOMY (FRENULECTOMY) $206.00 $155.00
D7963 FRENULOPLASTY $227.00 $135.00
D7970 EXC HYPERPLASTIC TISSUE-PER ARCH $232.00 $46.00
D7971 EXCISION OF PERICORONAL GINGIVA $115.00 $90.00
D7972 SURGICAL RDUC FIBROUS TUBEROSITY $110.00 $90.00
D7979 NON - SURGICAL SIALOLITHOTOMY BY REPORT BY REPORT
D7980 SIALOLITHOTOMY BY REPORT BY REPORT
D7981 EXCISION SALIVARY GLAND BY REPORT $330.00 $140.00
D7982 SIALODOCHOPLASTY BY REPORT BY REPORT
D7983 CLOSURE OF SALIVARY FISTULA BY REPORT BY REPORT
D7990 EMERGENCY TRACHEOTOMY $376.00 $160.00
D7991 CORONOIDECTOMY BY REPORT BY REPORT
D7995 SYNTH GFT-MAND/FACE BONES BY RPT BY REPORT BY REPORT
D7996 IMPLNT-MANDIB-AUGMENTATION BR BY REPORT BY REPORT
D7997 APPLIANCE REMV INCL REMV ARCHBAR BY REPORT BY REPORT
D7998 INTRAORAL PLCMT FIX DEVC NOT W/FX BY REPORT BY REPORT
D7999 UNS ORAL SURG PROC BY REPORT BY REPORT BY REPORT
D8010 LTD ORTHODONT TX PRIMARY DENTITION BY REPORT BY REPORT
D8020 LTD ORTHODONT TX TRNSITIONL DENTITN BY REPORT BY REPORT
D8030 LTD ORTHODONTIC TX ADOLES DENTITION BY REPORT BY REPORT
D8040 LTD ORTHODONTIC TX ADULT DENTITION BY REPORT BY REPORT
D8050 INTRCPTV ORTHODONT TX PRIM DENTITN BY REPORT BY REPORT
D8060 INTRCPTV ORTHODONT TX TRNSITNL DENT BY REPORT BY REPORT
D8070 COMP ORTHODONT TX TRNSITNL DENTITN BY REPORT BY REPORT
D8080 COMP ORTHODONT TX ADOLES DENTITION BY REPORT BY REPORT
D8090 COMP ORTHODONTIC TX ADULT DENTITION BY REPORT BY REPORT
D8210 REMOVABLE APPLIANCE THERAPY $279.00 $100.00
D8220 FIXED APPLIANCE THERAPY BY REPORT BY REPORT
D8660 PREORTHODONTIC TREATMENT VISIT BY REPORT BY REPORT
D8670 PERIODIC ORTHODONTIC TX VISIT BY REPORT BY REPORT
D8680 ORTHODONTIC RETENTION BY REPORT BY REPORT
D8681 REMOVABLE ORTHODONTIC RETAINER ADJ BY REPORT BY REPORT
D8690 ORTHODONTIC TREATMENT BY REPORT BY REPORT
D8691 REPAIR OF ORTHODONTIC APPLIANCE BY REPORT BY REPORT
D8692 REPLACEMENT LOST OR BROKEN RETAINER BY REPORT BY REPORT
D8693 REBONDING/RECEMENTING FIXED RETAINR BY REPORT BY REPORT
D8694 REPAIR FIX RETAINERS INCL REATTACH BY REPORT BY REPORT
D8695 REMV FIX ORTHODONT APPLINC RSN OTH THAN CMPL TX BY REPORT BY REPORT
D8999 UNS ORTHODONTIC PROCEDURE BY REPORT BY REPORT BY REPORT
D9110 PALLIATVE TX DENTAL PAIN-MINOR PROC $64.00 $50.00
D9120 FIXED PARTIAL DENTURE SECTIONING $215.00 $156.00
D9210 LOC ANES-NOT CONJUNC W/OP/SURG PROC BY REPORT BY REPORT
D9211 REGIONAL BLOCK ANESTHESIA BY REPORT BY REPORT
D9212 TRIGEMINAL DIVISION BLOCK ANES BY REPORT BY REPORT
D9215 LOCAL ANESTH CONJUNCT OP/SURG PROC BY REPORT BY REPORT
D9219 EVAL DEEP SEDATION/GEN ANESTHESIA BY REPORT BY REPORT
D9220 DEEP SEDATION GENERAL ANESTHESIA FIRST 30 MIN $182.00 $182.00
D9221 DEEP SEDATION GENERAL ANESTHESIA EACH ADD 15 MIN $65.00 $65.00
D9222 DEEP SEDATION/GENERAL ANESTHESIA-1ST 15 MINUTES $124.00 $124.00
D9223 DEEP SEDATION/GENERL ANES-EA 15 MIN $124.00 $70.00
D9230 INHAL NITROUS OXID/ANALG ANXIOLYSIS $70.00 $35.00
D9239 INTRAVENOUS MODERATE SEDAT/ANALGESIA-1ST 15 MINS $94.00 $94.00
D9243 IV MOD SEDATION/ANALGESIA-EA 15 MIN $94.00 $70.00
D9248 NON-INTRAVENOUS CONSCIOUS SEDATION BY REPORT BY REPORT
D9310 CNSLT DX DENT/PHY NOT REQ DENT/PHY $73.00 $47.00
D9311 CONSULTATION W/MED HEALTH CARE PROF BY REPORT BY REPORT
D9410 HOUSE/EXTENDED CARE FACILITY CALL BY REPORT BY REPORT
D9420 HOSPITAL OR AMB SURG CENTER CALL BY REPORT BY REPORT
D9430 OV OBS - NO OTH SERVICES PERFORMED $34.00 $27.00
D9440 OV-AFTER REGULARLY SCHEDULED HOURS $72.00 $20.00
D9450 CASE PRSATION DTL&EXT TX PLANNING BY REPORT BY REPORT
D9610 TX PARENTRAL DRUG 1 ADMINISTRATION BY REPORT BY REPORT
D9612 TX PARENTERAL RX 2/> ADMIN DIFF MED BY REPORT BY REPORT
D9630 DRUGS/MEDICAMNTS DISP OFFC HOME USE $26.00 $20.00
D9910 APPLICATION DESENZT MEDICAMENT BY REPORT BY REPORT
D9911 APPLIC DESENZT RSN CERV&/ROOT-TOOTH BY REPORT BY REPORT
D9920 BEHAVIOR MANAGEMENT BY REPORT BY REPORT BY REPORT
D9930 TX COMPS - UNUSUL CIRCUMSTANCES RPT $78.00 $58.00
D9932 CLEAN&INSPCT REMV CMPL DENTUR MAXIL BY REPORT BY REPORT
D9933 CLEAN&INSPECT REMV CMPL DENTUR MAND BY REPORT BY REPORT
D9934 CLEAN&INSPECT REMV PRT DENTUR MAXIL BY REPORT BY REPORT
D9935 CLEAN&INSPECT REMV PART DENTUR MAND BY REPORT BY REPORT
D9940 OCCLUSAL GUARD BY REPORT $279.00 $100.00
D9941 FABRICATION OF ATHLETIC MOUTHGUARD BY REPORT BY REPORT
D9942 REPAIR &/ RELINE OF OCCLUSAL GUARD BY REPORT BY REPORT
D9943 OCCLUSAL GUARD ADJUSTMENT BY REPORT BY REPORT
D9950 OCCLUSION ANALYSIS - MOUNTED CASE BY REPORT BY REPORT
D9951 OCCLUSAL ADJUSTMENT - LIMITED $149.00 $45.00
D9952 OCCLUSAL ADJUSTMENT - COMPLETE BY REPORT BY REPORT
D9970 ENAMEL MICROABRASION BY REPORT BY REPORT
D9971 ODONTPLSTY 1-2 TEETH;REMV ENAML PRJ BY REPORT BY REPORT
D9972 EXTERNAL BLEACH-PER ARCH-PRFRM OFF BY REPORT BY REPORT
D9973 EXTERNAL BLEACHING - PER TOOTH BY REPORT BY REPORT
D9974 INTERNAL BLEACHING - PER TOOTH BY REPORT BY REPORT
D9975 EXT BLEACH HOM APP-ARCH;MATL&TRAYS BY REPORT BY REPORT
D9985 SALES TAX BY REPORT BY REPORT
D9986 MISSED APPOINTMENT BY REPORT BY REPORT
D9987 CANCELLED APPOINTMENT BY REPORT BY REPORT
D9991 DENTAL CASE MGMT - ADR APPT CA BARR BY REPORT BY REPORT
D9992 DENTAL CASE MGMT - CARE COORDINATN BY REPORT BY REPORT
D9993 DENTAL CASE MGMT - MOTIVATIONL INTV BY REPORT BY REPORT
D9994 D CASE MGMT-PT ED IMP OR H LITERACY BY REPORT BY REPORT
D9995 TELEDENTISTRY - SYNCHRONOUS; REAL-TIME ENCOUNTER BY REPORT BY REPORT
D9996 TELEDENTISTRY-ASYNC; INFO STD&FWD DENT SUBSQ REV BY REPORT BY REPORT
D9999 UNS ADJUNCTIVE PROCEDURE REPORT BY REPORT BY REPORT

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