LAC 40:I.5399. Schedule for Maximum Allowances for Dental Services

CDT Code | Description | Maximum Reimbursement D0120 | Periodic oral evaluation—established patient | 50 D0140 | Limited oral evaluation—problem focused | 75 D0145 | Oral evaluation—patient under 3 yrs and counseling with primary caregiver | 69 D0150 | Comprehensive oral evaluation—new or established patient | 88 D0160 | Detailed and Extensive oral evaluation—problem focused | 160 D0170 | Re-evaluation—limited, problem focused (established patient; not post-operative visit | 70 D0180 | Comprehensive periodontal evaluation—new or established patient | 95 D0210 | Intraoral—complete series (including bitewings) | 128 D0220 | Intraoral—periapical first film | 28 D0230 | Intraoral—periapical each additional film | 24 D0240 | Intraoral—occlusal films | 42 D0250 | Intraoral—first film | 67 D0260 | Extraoral—first film | 55 D0270 | Bitewing—single film | 28 D0272 | Bitewing—two films | 45 D0273 | Bitewing—three films | 55 D0274 | Bitewing—four films | 65 D0277 | Vertical bitewings—7 to 8 films | 97 D0290 | Posterior-anterior or lateral skull and facial bone survey film | 135 D0310 | Sialography | 389 D0320 | Temporomandibular joint films, including injection | 592 D0321 | Other temporomandibular joint films | 210 D0322 | Tomographic survey | 530 D0330 | Panoramic film | 110 D0340 | Cephalometric film | 125 D0350 | Oral/facial photographic images | 71 D0360 | Cone beam CT—craniofacial data capture | 589 D0362 | Cone beam CT—two-dimensional image reconstruction using existing data, includes multiple images | 359 D0363 | Cone beam CT—three-dimensional image reconstruction using existing data, includes multiple images | 398 D0415 | Collection of microorganisms for culture and sensitivity | 186 D0416 | Viral culture | 168 D0417 | Collection and preparation of saliva sample for laboratory diagnostic testing | 167 D0418 | Analysis of saliva sample | 150 D0421 | Genetic test for susceptibility to oral diseases | 136 D0425 | Caries susceptibility tests | 95 D0431 | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures | 71 D0460 | Pulp vitality tests | 55 D0470 | Diagnostic casts | 109 D0472 | Accession of tissue, gross examination, preparation and transmission of written report | 118 D0473 | Accession of tissue, gross examination and microscopic examination, preparation and transmission of written report | 165 D0474 | Accession of tissue, gross examination and microscopic examination including assessment of surgical margins for presence of disease, preparation and transmission of written report | 184 D0480 | Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report | 176 D0486 | Accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report | 150 D0475 | Decalcification procedure | 195 D0476 | Special stains for microorganisms | 289 D0477 | Special stains not for microorganisms | 296 D0478 | Immunohistochemical stains | 175 D0479 | Tissue in-situ hybridization, including interpretation | 231 D0481 | Electron microscopy—diagnostic | 188 D0482 | Direct immunofluorescence | 105 D0483 | Indirect immunofluorescence | 123 D0484 | Consultation on slides prepared elsewhere | 168 D0485 | Consultation, including preparation of slides from biopsy material supplied by referring source | 180 D0502 | Other oral pathology procedures | 170 D0999 | Unspecified diagnostic procedure | BR D1110 | Prophylaxis—adult | 90 D1120 | Prophylaxis—child | 66 D1203 | Topical application of fluoride—child | 37 D1204 | Topical application of fluoride—adult | 37 D1206 | Topical fluoride varnish; therapeutic application for moderate to high caries risk patients | 45 D1310 | Nutritional counseling for control of dental disease | 70 D1320 | Tobacco counseling for the control and prevention of oral disease | 82 D1330 | Oral hygiene instructions | 55 D1351 | Sealant—per tooth | 54 D1352 | Preventative resin restoration in a moderate to high caries risk patient—permanent tooth | BR D1510 | Space maintainer—fixed—unilateral | 317 D1515 | Space maintainer—fixed—bilateral | 432 D1520 | Space maintainer—removable—unilateral | 390 D1525 | Space maintainer—removable—bilateral | 495 D1550 | Re-cementation of space maintainer | 83 D1555 | Removal of fixed space maintainer | 79 D2140 | Amalgam—one surface, primary or permanent | 138 D2150 | Amalgam—two surfaces, primary or permanent | 176 D2160 | Amalgam—three surfaces, primary or permanent | 214 D2161 | Amalgam—four surfaces, primary or permanent | 251 D2330 | Resin-based composite—one surface, anterior | 160 D2331 | Resin-based composite—two surfaces, anterior | 200 D2332 | Resin-based composite—three surfaces, anterior | 249 D2335 | Resin-based composite—four or more surfaces or involving incisal angle (anterior) | 312 D2390 | Resin-based composite crown—anterior | 450 D2391 | Resin-based composite—one surface, posterior | 177 D2392 | Resin-based composite—two surfaces, posterior | 230 D2393 | Resin-based composite—three surfaces, posterior | 284 D2394 | Resin-based composite—four or more surfaces posterior | 341 D2410 | Gold foil—one surface | 635 D2420 | Gold foil—two surfaces | 692 D2430 | Gold foil—three surfaces | 806 D2510 | Inlay—metallic—one surface | 833 D2520 | Inlay—metallic—two surfaces | 892 D2530 | Inlay—metallic—three or more surfaces | 965 D2542 | Onlay—metallic—two surfaces | 990 D2543 | Onlay—metallic—three surfaces | 1015 D2544 | Onlay—metallic—four or more surfaces | 1050 D2610 | Inlay—porcelain/ceramic—one surface | 907 D2620 | Inlay—porcelain/ceramic—two surfaces | 950 D2630 | Inlay—porcelain/ceramic—three or more surfaces | 995 D2642 | Onlay—porcelain/ceramic—two surfaces | 1008 D2643 | Onlay—porcelain/ceramic—three surfaces | 1049 D2644 | Onlay—porcelain/ceramic—four or more surfaces | 1094 D2650 | Inlay—resin based—one surface | 869 D2651 | Inlay—resin based—two surfaces | 904 D2652 | Inlay—resin based—three or more surfaces | 940 D2662 | Onlay—resin based—two surfaces | 944 D2663 | Onlay—resin based—three surfaces | 983 D2664 | Onlay—resin based—four or more surfaces | 1025 D2710 | Crown—resin-based composite (indirect) | 940 D2712 | Crown—3/4 resin-based composite (indirect) | 999 D2720 | Crown—resin with high noble metal | 1061 D2721 | Crown—resin with predominantly base metal | 998 D2722 | Crown—resin with noble metal | 1015 D2740 | Crown—porcelain/ceramic substrate | 1132 D2750 | Crown—porcelain fused to high noble metal | 1100 D2571 | Crown—porcelain fused predominantly base metal | 1029 D2752 | Crown—porcelain fused to noble metal | 1050 D2780 | Crown—3/4 cast high noble metal | 1063 D2781 | Crown—3/4 cast predominantly base metal | 1027 D2782 | Crown—3/4 cast noble metal | 1030 D2783 | Crown—3/4 porcelain /ceramic | 1100 D2790 | Crown—full cast high noble metal | 1100 D2791 | Crown—full cast predominantly base metal | 997 D2792 | Crown—full cast noble metal | 1045 D2794 | Crown—titanium | 1076 D2799 | Provisional crown | 437 D2910 | Recement inlay, only, or partial coverage restoration | 108 D2915 | Recement cast or prefabricated post and core | 114 D2920 | Recement crown | 109 D2930 | Prefabricated stainless steel crown—primary tooth | 271 D2931 | Prefabricated stainless steel crown—permanent tooth | 325 D2932 | Prefabricated resin crown | 351 D2933 | Prefabricated stainless steel crown with resin window | 363 D2934 | Prefabricated esthetic coated stainless steel crown—primary tooth | 372 D2940 | Protective restoration | 120 D2950 | Core buildup, including any pins | 271 D2951 | Pin retention—per tooth, in addition to restoration | 75 D2952 | Post and core in addition to crown, indirectly fabricated | 422 D2953 | Each additional indirectly fabricated post—same tooth | 312 D2954 | Prefabricated post and core in addition to crown | 335 D2955 | Post removal (not in conjunction with endodontic therapy) | 291 D2957 | Each additional prefabricated post—same tooth | 200 D2960 | Labial veneer (resin laminate)—chairside | 658 D2961 | Labial veneer (resin laminate)—laboratory | 975 D2962 | Labial veneer (porcelain laminate)—laboratory | 1150 D2970 | Temporary crown (fractured tooth) | 375 D2971 | Additional procedures to construct new crown under existing partial denture framework | 169 D2975 | Coping | 597 D2980 | Crown repair | 293 D2999 | Unspecified restorative procedure, | BR D3110 | Pulp cap—direct (excluding final restoration) | 83 D3120 | Pulp cap—indirect (excluding final restoration) | 84 D3220 | Therapeutic pulpotomy (excluding final restoration)—removal of pulp coronal to the dentinocemental junction and application of medicament | 198 D3221 | Pulpal debridement, primary and permanent teeth | 234 D3222 | Partial pulpotomy for apexogenesis—permanent tooth with incomplete root development | 298 D3230 | Pulpal therapy (resorbable filling)—anterior, primary tooth (excluding final restoration) | 275 D3240 | Pulpal therapy (resorbable filling)—posterior, primary tooth (excluding final restoration) | 312 D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | 725 D3320 | Endodontic therapy, biscuspid tooth (excluding final restoration) | 842 D3330 | Endodontic therapy, molar tooth (excluding final restoration) | 1009 D3331 | Treatment of root canal obstruction: non-surgical access | 611 D3332 | Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth | 444 D3333 | Internal root repair of perforation defects | 350 D3346 | Retreatment of previous root canal therapy—anterior | 850 D3347 | Retreatment of previous root canal therapy—bicuspid | 970 D3348 | Retreatment of previous root canal therapy—molar | 1132 D3351 | Apexification/recalcification/pulpal regeneration—initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) | 362 D3352 | Apexification/recalcification/pulpal regeneration—interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) | 258 D3353 | Apexification/recalcification/pulpal regeneration—final visit (includes completed root canal therapy—apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) | 542 D3354 | Pupal regeneration—(completion of regenerative treatment in an immature permanent tooth with a necrotic pulp); does not include final restoration | BR D3410 | Apicoectomy/periradicular surgery—anterior | 700 D3421 | Apicoectomy/periradicular surgery—bicuspid (first root) | 780 D3425 | Apicoectomy/periradicular surgery—molar (first root) | 895 D3426 | Apicoectomy/periradicular surgery—(each additional root) | 400 D3430 | Retrograde filling—per root | 280 D3450 | Root amputation—per root | 483 D3460 | Endodontic endosseous implant | 1524 D3470 | Intentional reimplantation (including necessary splinting) | 796 D3910 | Surgical procedure for isolation of tooth with rubber dam | 235 D3920 | Hemisection (including any root removal), not including root canal therapy | 474 D3950 | Canal preparation and fitting of preformed dowel or post | 258 D3999 | Unspecified endodontic procedure, | BR D4210 | Gingivectomy or gingivoplasty—four or more contiguous teeth or tooth bounded spaces per quadrant | 626 D4211 | Gingivectomy or gingivoplasty—one to three contiguous teeth or tooth bounded spaces per quadrant | 290 D4230 | Anatomical crown exposure—four or more contiguous teeth per quadrant | 698 D4231 | Anatomical crown exposure—one to three contiguous teeth per quadrant | 596 D4240 | Gingival flap procedure, including root planing—one to three contiguous teeth or tooth bounded spaces per quadrant | 738 D4241 | Gingival flap procedure, including root planing—four or more contiguous teeth or tooth bounded spaces per quadrant | 635 D4245 | Apically positioned flap | 819 D4249 | Clinical crown lengthening—hard tissue | 751 D4260 | Osseous surgery (including flap entry and closure)—four or more contiguous teeth or tooth bounded spaces per quadrant | 1074 D4261 | Osseous surgery (including flap entry and closure)—one to three contiguous teeth or tooth bounded spaces per quadrant | 890 D4263 | Bone replacement graft—each additional site in quadrant | 727 D4264 | Bone replacement graft—first site in quadrant | 555 D4265 | Biologic materials to aid in soft and osseous tissue regeneration | 550 D4266 | Guided tissue regeneration—resorbable barrier, per site | 831 D4267 | Guided tissue regeneration—nonresorbable barrier, per site (includes membrane removal) | 984 D4268 | Surgical revision procedure, per tooth | 810 D4270 | Pedical soft tissue graft procedure | 826 D4271 | Free soft tissue graft procedure (including donor site surgery) | 895 D4273 | Subepithelial connective tissue graft procedures, per tooth | 1088 D4274 | Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) | 670 D4275 | Soft tissue allograft | 969 D4276 | Combined connective tissue and double pedicle graft, per tooth | 1085 D4320 | Provisional splinting—intracoronal | 508 D4321 | Provisional splinting—extracoronal | 466 D4341 | Periodontal scaling and root planing—four or more teeth per quadrant | 251 D4342 | Periodontal scaling and root planing—one to three teeth per quadrant | 185 D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | 183 D4381 | Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, | 140 D4910 | Periodontal maintenance | 139 D4920 | Unscheduled dressing change (by someone other than treating dentist) | 100 D4999 | Unspecified periodontal procedure, | BR D5110 | Complete denture—maxillary | 1689 D5120 | Complete denture—mandibular | 1700 D5130 | Immediate denture—maxillary | 1831 D5140 | Immediate denture—mandibular | 1849 D5211 | Maxillary partial denture—resin base (including any conventional clasps, rests and teeth) | 1350 D5212 | Mandibular partial denture—resin base (including any conventional clasps, rests and teeth) | 1350 D5213 | Maxillary partial denture—cast base framework with resin denture bases (including any conventional clasps, rests and teeth) | 1781 D5214 | Mandibular partial denture—cast base framework with resin denture bases (including any conventional clasps, rests and teeth) | 1780 D5225 | Maxillary partial denture—flexible base (including any clasps, rests and teeth) | 1566 D5226 | Mandibular partial denture—flexible base (including any clasps, rests and teeth) | 1552 D5281 | Removable unilateral partial denture—one piece cast metal (including clasps and teeth) | 995 D5410 | Adjust complete denture—maxillary | 89 D5411 | Adjust complete denture—mandibular | 88 D5421 | Adjust partial denture—maxillary | 88 D5422 | Adjust partial denture—mandibular | 88 D5510 | Repair broken complete denture base | 208 D5520 | Replace missing or broken teeth—complete denture (each tooth) | 186 D5610 | Repair resin denture base | 202 D5620 | Repair cast framework | 291 D5630 | Repair or replace broken clasp | 262 D5640 | Replace broken teeth—per tooth | 184 D5650 | Add tooth to existing partial denture | 224 D5660 | Add clasp to existing partial denture | 268 D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | 735 D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | 750 D5710 | Rebase complete maxillary denture | 591 D5711 | Rebase complete mandibular denture | 585 D5720 | Rebase maxillary partial denture | 563 D5721 | Rebase mandibular partial denture | 562 D5730 | Reline complete maxillary denture (chairside) | 372 D5731 | Reline complete mandibular denture (chairside) | 369 D5740 | Reline maxillary partial denture (chairside) | 364 D5741 | Reline mandibular partial denture (chairside) | 368 D5750 | Reline complete maxillary denture (laboratory) | 475 D5751 | Reline complete mandibular denture (laboratory) | 475 D5760 | Reline maxillary partial denture (laboratory) | 469 D5761 | Reline mandibular partial denture (laboratory) | 472 D5810 | Interim complete denture (maxillary) | 848 D5811 | Interim complete denture (mandibular) | 853 D5820 | Interim partial denture (maxillary) | 690 D5821 | Interim partial denture (mandibular) | 690 D5850 | Tissue conditioning, maxillary | 204 D5851 | Tissue conditioning, mandibular | 205 D5860 | Overdenture—complete | 2121 D5861 | Overdenture—partial | 2048 D5862 | Precision attachment | 700 D5867 | Replacement of replaceable part of semi-precision or precision attachment (male or female component) | 385 D5875 | Modification of removable prosthesis following implant surgery | 393 D5899 | Unspecified removable prosthodontic procedure | BR D5911 | Facial moulage (sectional) | BR D5912 | Facial moulage (complete) | BR D5913 | Nasal prosthesis | BR D5914 | Auricular prosthesis | BR D5915 | Orbital prosthesis | BR D5916 | Ocular prosthesis | BR D5919 | Facial prosthesis | BR D5923 | Ocular prosthesis, interim | BR D5924 | Cranial prosthesis | BR D5925 | Facial augmentation implant prosthesis | BR D5926 | Nasal prosthesis, replacement | BR D5957 | Auricular prosthesis, replacement | BR D5958 | Orbital prosthesis, replacement | BR D5929 | Facial prosthesis, replacement | BR D5931 | Obturator prosthesis, surgical | BR D5932 | Obturator prosthesis, definitive | BR D5933 | Obturator prosthesis, modification | BR D5934 | Mandibular resection prosthesis with guide flange | BR D5935 | Mandibular resection prosthesis without guide flange | BR D5936 | Obturator prosthesis interim | BR D5937 | Trismus appliance (not for TMD treatment) | 746 D5951 | Feeding aid | 844 D5952 | Speech aid prosthesis, pediatric | BR D5953 | Speech aid prosthesis, adult | BR D5954 | Palatal augmentation prosthesis | BR D5955 | Palatal lift prosthesis, definitive | BR D5958 | Palatal lift prosthesis, interim | BR D5959 | Palatal lift prosthesis, modification | BR D5960 | Speech aid prosthesis modification | BR D5982 | Surgical stent | 450 D5983 | Radiation carrier | BR D5984 | Radiation shield | BR D5985 | Radiation cone locater | BR D5986 | Fluoride gel carrier | 210 D5987 | Commissure splint | BR D5988 | Surgical splint | 770 D5991 | Topical medicament carrier | 226 D5992 | Adjust maxillofacial prosthetic appliance | BR D5993 | Maintenance and cleaning of maxillofacial prosthesis (extra or intraoral) other than required adjustments | BR D5999 | Unspecified maxillofacial prosthesis | BR D6190 | Radiographic/surgical implant index | 375 D6010 | Surgical placement of implant body: endosteal implant | 2001 D6012 | Surgical placement of interim implant body for transitional prosthesis: endosteal implant | 1577 D6040 | Surgical placement: eposteal implant | 8380 D6050 | Surgical placement: transosteal implant | 5807 D6100 | Implant removal | 760 D6055 | Connecting bar—implant supported abutment support | 2900 D6506 | Prefabricated abutment—includes placement | 789 D6057 | Custom abutment—includes placement | 952 D6053 | Implant/abutment supported removable denture for completely edentulous arch | 2790 D6054 | Implant/abutment supported removable denture for partially edentulous arch | 2751 D6078 | Implant/abutment supported fixed denture for completely edentulous arch | 5335 D6079 | Implant/abutment supported fixed denture for partially edentulous arch | 3800 D6058 | Abutment supported porcelain/ceramic crown | 1479 D6059 | Abutment supported porcelain/ceramic crown (high noble metal) | 1479 D6060 | Abutment supported porcelain fused to metal crown (predominately base metal) | 1361 D6061 | Abutment supported porcelain fused to metal crown (noble metal) | 1382 D6062 | Abutment supported cast metal crown (high noble metal) | 1432 D6063 | Abutment supported cast metal crown (predominantly base metal) | 1317 D6064 | Abutment supported cast metal crown (noble metal) | 1366 D6094 | Abutment supported crown—(titanium) | 1376 D6065 | Implant supported porcelain/ceramic crown | 1543 D6066 | Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | 1545 D6067 | Implant supported metal crown (titanium, titanium alloy, high noble metal) | 1575 D6068 | Abutment supported retainer for porcelain/ceramic FPD | 1469 D6069 | Abutment supported retainer for porcelain fused to metal FPD (high noble metal) | 1474 D6070 | Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) | 1384 D6071 | Abutment supported retainer for porcelain fused to metal FPD (noble metal) | 1384 D6072 | Abutment supported retainer for cast metal FPD (high noble metal) | 1451 D6073 | Abutment supported retainer for porcelain cast metal FPD (predominantly base metal) | 1384 D6074 | Abutment supported retainer for cast metal FPD (noble metal) | 1384 D6194 | Abutment supported retainer crown for FPD (titanium) | 1392 D6075 | Implant supported retainer for ceramic FPD | 1529 D6076 | Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy or high noble metal | 1538 D6077 | Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal) | 1587 D6080 | Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis | 297 D6090 | Repair implant supported prosthesis | 742 D6095 | Repair implant abutment | 731 D6091 | Replacement of semi-precious or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment | 631 D6092 | Recement implant/abutment supported crown | 160 D6093 | Recement implant/abutment supported fixed partial denture | 182 D6199 | Unspecified implant procedure | BR D6205 | Pontic—indirect resin based composite | 988 D6210 | Pontic—cast high noble metal | 1089 D6211 | Pontic—cast predominately base metal | 998 D6212 | Pontic—cast noble metal | 1041 D6214 | Pontic—titanium | 1100 D6240 | Pontic—porcelain fused to high noble metal | 1100 D6241 | Pontic—porcelain fused to predominantly base metal | 1024 D6242 | Pontic—porcelain fused to noble metal | 1051 D6245 | Pontic—porcelain/ceramic | 1140 D6250 | Pontic—resin with high noble metal | 1058 D6251 | Pontic—resin with predominantly base metal | 1049 D6252 | Pontic—resin with noble metal | 1040 D6253 | Provisional pontic | 769 D6254 | Interim pontic | BR D6545 | Retainer—cast metal for resin bonded fixed prosthesis | 852 D6548 | Retainer—porcelain/ceramic for resin bonded fixed prosthesis | 950 D6600 | Inlay—porcelain/ceramic, two surfaces | 1000 D6601 | Inlay—porcelain/ceramic, three or more surfaces | 1052 D6602 | Inlay—cast high noble metal, two surfaces | 1015 D6603 | Inlay—cast high noble metal, three or more surfaces | 1050 D6604 | Inlay—predominantly base metal, two surfaces | 994 D6605 | Inlay—predominantly base metal, three or more surfaces | 1046 D6606 | Inlay—cast noble metal, two surfaces | 998 D6607 | Inlay—cast noble metal, three or more surfaces | 1050 D6624 | Inlay—titanium | 1080 D6608 | Onlay—porcelain/ceramic, two surfaces | 1061 D6609 | Onlay—porcelain/ceramic, three or more surfaces | 1127 D6610 | Onlay—cast high noble metal, two surfaces | 1074 D6611 | Onlay—cast high noble metal, three or more surfaces | 1111 D6612 | Onlay—predominantly base metal, two surfaces | 1038 D6613 | Onlay—predominantly base metal, three or more surfaces | 1095 D6614 | Onlay—cast noble metal, two surfaces | 1050 D6615 | Onlay—cast noble metal, three or more surfaces | 1102 D6634 | Onlay—titanium | 1125 D6710 | Crown—indirect resin based composite | 1025 D6720 | Crown—resin with high noble metal | 1056 D6721 | Crown—resin with predominantly base metal | 1032 D6722 | Crown—resin with noble metal | 1050 D6740 | Crown—porcelain/ceramic | 1146 D6750 | Crown—porcelain fused to high noble metal | 1107 D6751 | Crown—porcelain fused to predominantly base metal | 1010 D6752 | Crown—porcelain fused to noble metal | 1050 D6780 | Crown—3/4 cast high noble metal | 1075 D6781 | Crown—3/4 cast predominantly base metal | 1038 D6782 | Crown—3/4 cast noble metal | 1050 D6783 | Crown—3/4 porcelain/ceramic | 1100 D6790 | Crown—full cast high noble metal | 1085 D6791 | Crown—full cast predominantly base metal | 997 D6792 | Crown—full cast noble metal | 1040 D6794 | Crown—titanium | 1059 D6793 | Provisional retainer crown | 523 D6795 | Interim retainer crown | BR D6920 | Connector bar | 995 D6930 | Recement fixed partial denture | 171 D6940 | Stress breaker | 435 D6950 | Precision attachment | 650 D6970 | Post and core in addition to fixed partial denture retainer, indirectly fabricated | 433 D6972 | Prefabricated post and core in addition to fixed partial denture retainer | 344 D6973 | Core build up for retainer, including any pins | 275 D6975 | Coping—metal | 700 D6976 | Each additional indirectly fabricated post—same tooth | 290 D6977 | Each additional prefabricated post—same tooth | 204 D6980 | Fixed partial denture repair | 387 D6985 | Pediatric partial denture, fixed | 915 D6999 | Unspecified fixed prosthodontic procedure | BR D7111 | Extraction, coronal remnants—deciduous tooth | 135 D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | 174 D7210 | Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | 275 D7220 | Removal of impacted tooth—soft tissue | 315 D7230 | Removal of impacted tooth—partially bony | 395 D7240 | Removal of impacted tooth—completely bony | 484 D7241 | Removal of impacted tooth—completely bony, with unusual surgical complications | 576 D7250 | Surgical removal of residual tooth roots (cutting procedure) | 304 D7251 | Coronectomy—intentional partial tooth removal | BR D7260 | Oroantral fistula closure | 1026 D7261 | Primary closure of a sinus perforation | 757 D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | 561 D7272 | Tooth tranplantation (includes reimplantation from one site to another and splinting and/or stabilization) | 746 D7280 | Surgical access of an unerupted tooth | 482 D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | 526 D7283 | Placement of device to facilitate eruption of impacted tooth | 523 D7285 | Biopsy of oral tissue—hard (bone, tooth) | 437 D7286 | Biopsy of oral tissue—soft | 320 D7287 | Exfoliative cytological sample collection | 184 D7288 | Brush biopsy—transepithelial sample collection | 195 D7290 | Surgical repositioning of teeth | 528 D7291 | Transseptal fiberotomy/surpa crestal fibertotomy | 315 D7292 | Surgical placement: temporary anchorage device [screw retained plate] requiring surgical flap | 3300 D7293 | Surgical placement: temporary anchorage device requiring surgical flap | 2528 D7294 | Surgical placement: temporary anchorage device without surgical flap | 1619 D7295 | Harvest of bone for use in autogenous grafting procedure | BR D7310 | Alveolplasty in conjunction with extractions—four or more teeth or tooth spaces, per quadrant | 295 D7311 | Alveolplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant | 309 D7320 | Alveolplasty not in conjunction with extractions—four or more teeth or tooth spaces, per quadrant | 443 D7321 | Alveolplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant | 437 D7340 | Vestibuloplasty—ridge extension (secondary epithelialization) | 1164 D7350 | Vestibuloplasty—ridge extension (including soft tissue graft, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) | 2467 D7410 | Excision of benign lesion up to 1.25 cm | 415 D7411 | Excision of benign lesion greater than 1.25 cm | 630 D7412 | Excision of benign lesion, complicated | 850 D7413 | Excision of malignant lesion greater than 1.25 cm | 751 D7414 | Excision of malignant lesion up to 1.25 cm | 1132 D7415 | Excision of malignant lesion, complicated | 1253 D7465 | Destruction of lesion(s) by physical or chemical method | 459 D7440 | Excision of malignant tumor—lesion diameter up to 1.25 cm | 720 D7441 | Excision of malignant tumor—lesion greater than 1.25 cm | 1224 D7450 | Removal of benign odontogenic cyst or tumor—lesion diameter up to 1.25 cm | 588 D7451 | Removal of benign odontogenic cyst or tumor—lesion diameter greater than 1.25 cm | 782 D7460 | Removal of benign nonodontogenic cyst or tumor—lesion diameter greater than 1.25 cm | 573 D7461 | Removal of benign nonodontogenic cyst or tumor—lesion diameter up to 1.25 cm | 874 D7470 | Removal of lateral exostosis (maxilla or mandible) | 653 D7472 | Removal of torus palatinus | 859 D7473 | Removal of torus mandibularis | 761 D7485 | Surgical reduction of osseous tuberosity | 755 D7490 | Radial resection of maxilla or mandible | 8006 D7510 | Incision and drainage of abscess—intraoral soft tissue | 236 D7511 | Incision and drainage of abscess—intraoral soft tissue—complicated (includes drainage of multiple fascial spaces) | 367 D7520 | Incision and drainage of abscess—extraoral tissue | 169 D7521 | Incision and drainage of abscess—extraoral tissue—complicated (includes drainage of multiple fascial spaces) | 630 D7530 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | 364 D7540 | Removal of reaction producing foreign bodies, musculoskeletal system | 708 D7550 | Partial ostectomy/sequestrectomy for removal of non-vital bone | 600 D7560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | 1308 D7610 | Maxilla—open reduction (teeth immobilized, if present) | 4464 D7620 | Maxilla—closed reduction (teeth immobilized, if present) | 3450 D7630 | Mandible—open reduction (teeth immobilized, if present) | 4576 D7640 | Mandible—closed reduction (teeth immobilized, if present) | 3483 D7650 | Malar and/or zygomatic arch—open reduction | 3924 D7660 | Malar and/or zygomatic arch—closed reduction | 3277 D7670 | Alveolus closed reduction may include stabilization of teeth | 1746 D7671 | Alveolus open reduction may include stabilization of teeth | 1298 D7680 | Facial bones—complicated reduction with fixation and multiple surgical approaches | 6555 D7710 | Maxilla open reduction | 4568 D7720 | Maxilla—closed reduction | 3462 D7730 | Mandible—open reduction | 4826 D7740 | Mandible—closed reduction | 3636 D7750 | Malar and/or zygomatic arch—open reduction | 4230 D7760 | Malar and/or zygomatic arch—closed reduction | 6044 D7770 | Alveolus open reduction stabilization of teeth | 2794 D7771 | Alveolus closed reduction stabilization of teeth | 1958 D7780 | Facial bones—complicated reduction with fixation and multiple surgical approaches | 8587 D7810 | Open reduction of dislocation | 4271 D7820 | Closed reduction of dislocation | 644 D7830 | Manipulation under anesthesia | 990 D7840 | Condylectomy | 5466 D7850 | Surgical discectomy, with/without implant | 5356 D7852 | Disc repair | 5541 D7854 | Synovectomy | 5278 D7856 | Myotomy | 3505 D7858 | Joint reconstruction | BR D7860 | Arthrotomy | BR D7865 | Arthroplasty | BR D7870 | Arthrocentesis | 562 D7871 | Non-arthroscopic lysis and lavage | BR D7872 | Arthroscopy—diagnosis, with or without biopsy | BR D7873 | Arthroscopy—surgical: lavage and lysis of adhesions | BR D7874 | Arthroscopy—surgical: disc repositioning and stabilization | BR D7875 | Arthroscopy—surgical: synovectomy | BR D7876 | Arthroscopy—surgical: discectomy | BR D7877 | Arthroscopy—surgical: debridement | BR D7880 | Occlusal orthotic device | 990 D7899 | Unspecified TMD therapy | BR D7910 | Suture of recent small wounds up to 5 cm | 300 D7911 | Complicated suture—up to 5 cm | 486 D7912 | Complicated suture—greater than 5 cm | 792 D7920 | Skin graft (identify defect covered, location and type of graft | 2677 D7940 | Osteoplasty—for orthognathic deformaties | 4123 D7941 | Osteotomy—mandibular rami | 9139 D7943 | Osteotomy—mandibular rami with bone graft; includes obtaining the graft | 8623 D9744 | Osteotomy—segmented or subapical | 7006 D7945 | Osteotomy—body of mandible | 6983 D7946 | LeFort I (maxilla—total) | 8251 D7947 | LeFort I (maxilla—segmentedl) | 8393 D7948 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion)without bone graft | 9586 D7949 | LeFort II of LeFort III—with bone graft | 11832 D7950 | Osseous, osteoperiosteal or cartilage graft of the mandible or maxilla—autogenous or nonautogenous | 3116 D7951 | Sinus augmentation with bone or bone substitutes | 3200 D7953 | Bone replacement graft for ridge preservation—per site | 800 D7955 | Repair of maxillofacial soft and/or hard tissue defect | 3807 D7960 | Frenulectomy—also known as frenectomy or frenotomy—separate procedure not incidental to another procedure | 450 D7936 | Frenuloplasty | 499 D7970 | Excision of hyperplastic tissue—per arch | 517 D7971 | Excision of pericoronal gingiva | 258 D7972 | Surgical reduction of fibrous tuberosity | 796 D7980 | Sialolithotomy | 843 D7981 | Excision of salivary gland | BR D7982 | Sialodochoplasty | 1749 D7983 | Closure of salivary fistula | 1528 D7990 | Emergency tracheotomy | 1482 D7991 | Coronoidectomy | 4056 D7995 | Synthetic graft—mandible or facial bones | BR D7996 | Implant-mandible for augmentation purposes (excluding alveolar ridge) | BR D7997 | Appliance removal (not by dentist who place appliance), includes removal of archbar | 350 D7998 | Intraoral placement of a fixation device not in conjunction with a fracture | 2572 D7999 | Unspecified oral surgery procedure | BR D8010 | Limited orthodontic treatment of the primary dentition | 2149 D8020 | Limited orthodontic treatment of the transitional dentition | 2459 D8030 | Limited orthodontic treatment of the adolescent dentition | 2901 D8040 | Limited orthodontic treatment of the adult dentition | 3237 D8050 | Interceptive orthodontic treatment of the primary dentition | 2590 D8060 | Interceptive orthodontic treatment of the transitional dentition | 2796 D8070 | Comprehensive orthodontic treatment of the transitional dentition | 5200 D8080 | Comprehensive orthodontic treatment of the adolescent dentition | 5250 D8090 | Comprehensive orthodontic treatment of the adult dentition | 5308 D8210 | Removable appliance therapy | 861 D8220 | Fixed appliance therapy | 968 D8660 | Pre-orthodontic treatment visit | 384 D8670 | Periodic orthodontic treatment visit (as part of contract) | 263 D8680 | Orthodontic retention (removal of appliances, construction and placement of retainers(s)) | 532 D8690 | Orthodontic treatment (alternative billing to a contract fee) | 283 D8691 | Repair of orthodontic appliance | 210 D8692 | Replacement of lost or broken retainer | 330 D8693 | Rebonding or recementing; and/or repair as require, of fixed retainers | 356 D8999 | Unspecified orthodontic procedure, | BR D9110 | Palliative (emergency) treatment of dental pain—minor procedure | 126 D9120 | Fixed partial denture sectioning | 250 D9210 | Local anesthesia not in conjunction with operative or surgical procedures | 74 D9211 | Regional block anesthesia | 96 D9212 | Trigeminal division block anesthesia | 272 D9215 | Local anesthesia in conjunction with operative or surgical procedures | 65 D9220 | Deep sedation/general anesthesia—first 30 minutes | 392 D9221 | Deep sedation/general anesthesia—each additional 15 minutes | 174 D9230 | Inhalation of nitrous oxide/anxiolysis analgesia | 79 D9241 | Intravenous conscious sedation/analgesia—first 30 minutes | 416 D9242 | Intravenous conscious sedation/analgesia—each additional 15 minutes | 169 D9248 | Non-intravenous conscious sedation | 325 D9310 | Consultation—diagnostic services provided by dentist or physician other than requesting dentist or physician | 129 D9410 | House/extended care facility call | 246 D9420 | Hospital or ambulatory surgery center call | 299 D9430 | Office visit for observation (during regularly scheduled hours)—no other services performed | 76 D9440 | Office visit after regularly scheduled hours | 179 D9450 | Case presentation, detailed and extensive treatment planning | 145 D9610 | Therapeutic parental drug, single administration | 111 D9612 | Therapeutic parental drug, two or more administrations, different medications | 193 D9630 | Other drugs and/or medicaments | 49 D9910 | Application of disensitizing medicament | 63 D9911 | Application of disensitizing resin for cervical and/or root surface, per tooth | 79 D9920 | Behavior management | 160 D9930 | Treatment of complications (post-surgical)—unusual circumstances | 132 D9940 | Occlusal guard, | 600 D9941 | Fabrication of athletic mouthguard | 254 D9942 | Repair and/or reline of occlusal guard | 250 D9950 | Occulusion analysis—mounted case | 344 D9951 | Occulusal adjustment—limited | 182 D9952 | Occulusal adjustment—complete | 687 D9970 | Enamel microabrasion | 202 D9971 | Odontoplasty 1-2 teeth; includes removal of enamel projections | 176 D9972 | External bleaching—per arch | 328 D9973 | External bleaching—per tooth | 231 D9974 | Internal bleaching—per tooth | 291 D9999 | Unspecified adjunctive procedure | BR