Retiree Health & Welfare
Health & Welfare Plan
Price Comparison and Transparency
Provider Price Comparison Tools
Dental PPO Price Comparison
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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 | NOT COVERED | NOT COVERED |
| 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 |