Exhibits_A-C.PDF

TRICARE DENTAL READINESS AND WELLNESS

HT9402-17-R-0001

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D0120 Periodic oral evaluation - established patient 58,000 737

D0140 Limited oral evaluation - problem focused 55,000 49

D0150 Comprehensive oral evaluation - new or established patient 30,000 377

D0160 Detailed and extensive oral evaluation -problem focused, by report 400 1

D0170 Re-evaluation - limited, problem focused (established patient, not post-operative visit) 250 0

D0171 re-evaluation - post-operative office visit 20 0

D0180 Comprehensive periodontal evaluation -new or established patient 2,500 7

D0190 Screening of a patient 1 0 D0191 Assessment of a patient 1 0

D0210 Intraoral - complete series of radiographic images 14,000 60

D0220 Intraoral - periapical first radiographic image 40,000 197

D0230 Intraoral - periapical each additional radiographic image 30,000 20

D0240 Intraoral - occlusal radiographic image 60 3

D0250 Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector 10 3

D0251 Extraoral posterior dental radiographic image 10 0

D0270 Bitewing - single radiographic image 3,100 156 D0272 Bitewings - two radiographic images 5,000 179 D0273 Bitewings - three radiographic images 150 12 D0274 Bitewings - four radiographic images 47,100 257

D0277 Vertical bitewings - 7 to 8 radiographic images 325 0

D0310 Sialography 1 0

D0320 Temporomandibular joint arthrogram, including injection 5 1

D0321 Other temporomandibular joint radiographic images, by report 5 0

D0322 Tomographic survey 25 4 D0330 Panoramic radiographic image 22,000 429

D0340 2D cephalometric radiographic image -acquisition, measurement and analysis 125 1

D0350 Oral/facial photographic image obtained intraorally or extraorally 400 3

D0351 3D photographic image 10 3

D0364 Cone beam CT capture and interpretation with limited field of view - less than one whole jaw 1,400 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D0365 Cone beam CT capture and interpretation with limited field of view of one full dental arch - mandible 350 0

D0366

Cone beam CT capture and interpretation with limited field of view of one full dental arch - maxilla, with or without cranium 350 0

D0367 Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium 1,000 1

D0368 Cone beam CT capture and interpretation for TMJ series including two or more exposures 25 0

D0369 Maxillofacial MRI capture and interpretation 25 0

D0370 Maxillofacial ultrasound capture and interpretation 25 1

D0371 Sialoendoscopy capture and interpretation 1 0

D0380 Cone beam CT image capture with limited field of view - less than one whole jaw 150 0

D0381 Cone beam CT image capture with limited field of view of one full dental arch -mandible 50 0

D0382 Cone beam CT imagae capture with limited field of view of one full dental arch - maxilla, with or without cranium 30 0

D0383 Cone beam CT image capture with field of view of both jaws, with or without cranium 100 0

D0384 Cone beam CT image capture for TMJ series including two or more exposures 5 0

D0385 Maxillofacial MRI image capture 1 0 D0386 Maxillofacial ultrasound image capture 1 0

D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report 40 0

D0393 Treatment simulation using 3D image volume 200 1

D0394 Digital subtraction of two or more images or image volumes of the same modality 50 1

D0395 Fusion of two or more 3D image volumes of one or more modalities 50 0

D0411 HbA1c in-office point of service testing 100

D0414

Laboratory processing of microbial speciment to include culture and sensitivity studies, preparation and transmission of written report 10 0

D0415 Collection of microorganisms for culture and sensitivity 10 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D0416 Viral culture 1 0

D0417 Collection and preparation of saliva sample for laboratory diagnostic testing 1 1

D0418 Analysis of saliva sample 1 0

D0422 Collection and preparation of genetic sample material for laboratory anlysis and report 1 0

D0423 Genetic test for susceptibility to deseasees - specimen analysis 1 0

D0425 Caries susceptibility tests 5 0

D0431

Adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures 20 0

D0460 Pulp vitality tests 40 15 D0470 Diagnostic casts 500 4

D0472 Accession of tissue, gross examination preparation and transmission of written report 1 1

D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report 5 0

D0474

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report 25 0

D0475 Decalcification procedure 3 0 D0476 Special stains for microorganisms 1 0 D0477 Special stains, not for microorganisms 2 0 D0478 Imminohistochemical stains 1 0

D0479 Tissue in-situ hybridization, including interpretation 1 0

D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report 1 0

D0481 Electron microscopy - diagnostic 1 0 D0482 Direct immunofluorescence 1 0 D0483 Indirect immunofluorescence 1 0

D0484 Consultation on slides prepared elsewhere 5 0

D0485 Consultation, including preparation of slides from biopsy material supplied by referring source 5 0

D0486

Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report 3 1

D0502 Other oral pathology procedures, by report 3 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D0600

Non-ionizingdiagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum 1 0

D0601 Caries risk assessment and documentation, with a finding of low risk 1 0

D0602 Caries risk assessment and documentation, with a finding of moderate risk 1 0

D0603 Caries risk assessment and documentation, with a finding of high risk 1 0

D0999 Unspecified diagnostic procedure, by report 10 3

D1110 Prophylaxis - adult 90,000 899 D1206 Topical application of fluoride varnish 17,000 11 D1208 Topical application of fluoride 25,000 225

D1310 Nutritional counseling for control of dental disease 1 0

D1320 Tobacco counseling for the control and prevention of oral disease 1 0

D1330 Oral hygiene instructions 15 7 D1351 Sealant - per tooth 500 31

D1352 Preventive resin restoration in a moderate to high caries risk patient -permanent tooth 300 17

D1353 Sealant repair - per tooth 1 0

D1354 Interim caries arresting medicament appplication 25 0

D1510 Space maintainer - fixed - unilateral 3 0 D1515 Space maintainer - fixed - bilateral 1 0

D1520 Space maintainer - removable - unilateral 5 0

D1525 Space maintainer - removable - biilateral 1 0 D1550 Re-cementation of space maintainer 2 0 D1555 Removal of fixed space maintainer 2 0

D1575 Distal shoe space maintainer-fixed-unilateral 1 0

D1999 Unspecified preventive procedure, by report 5 7

D2140 Amalgam - one surface, primary or permanent 5,000 4

D2150 Amalgam - two surfaces, primary or permanent 10,000 3

D2160 Amalgam - three surfaces, primary or permanent 5,000 1

D2161 Amalgam - four or more surfaces, primary or permanent 1,000 9

D2330 Resin-based composite - one surface, anterior 5,000 112

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D2331 Resin-based composite - two surfaces, anterior 5,000 56

D2332 Resin-based composite - three surfaces, anterior 3,500 16

D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) 2,500 17

D2390 Resin-based composite crown, anterior 10 3

D2391 Resin-based composite - one surface, posterior 20,000 56

D2392 Resin-based composite - two surfaces, posterior 24,000 73

D2393 Resin-based composite - three surfaces, posterior 10,000 31

D2394 Resin-based composite - four or more surfaces, posterior 2,000 9

D2410 Gold foil - one surface 1 3 D2420 Gold foil - two surfaces 1 0 D2430 Gold foil - three surfaces 1 0 D2510 Inlay - metallic - one surface 1 0 D2520 Inlay - metallic - two surfaces 1 0 D2530 Inlay - metallic - three or more surfaces 5 0 D2542 Onlay - metallic - two surfaces 2 1 D2543 Onlay - metallic - three surfaces 5 1 D2544 Onlay - metallic - four or more surfaces 5 1 D2610 Inlay - porcelain/ceramic - one surface 1 8 D2620 Inlay - porcelain/ceramic - two surfaces 5 1

D2630 Inlay - porcelain/ceramic - three or more surfaces 5 1

D2642 Onlay - porcelain/ceramic - two surfaces 5 3

D2643 Onlay - porcelain/ceramic - three surfaces 25 0

D2644 Onlay - porcelain/ceramic - four or more surfaces 20 0

D2650 Inlay - resin-based composite - one surface 1 8

D2651 Inlay - resin-based composite - two surfaces 1 3

D2652 Inlay - resin-based composite - three or more surfaces 1 3

D2662 Onlay - resin-based composite - two surfaces 1 1

D2663 Onlay - resin-based composite - three surfaces 1 3

D2664 Onlay - resin-based composite - four or more surfaces 1 0

D2710 Crown - resin - based composite (indirect) 1 4

D2712 Crown - 3/4 resin-based composite (indirect) 1 9

D2720 Crown - resin with high noble metal 1 3

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D2721 Crown - resin with predominantly base metal 1 1

D2722 Crown - resin with noble metal 1 0 D2740 Crown - porcelain/ceramic substrate 6,500 19

D2750 Crown - porcelain fused to high noble metal 8,000 95

D2751 Crown - porcelain fused to predominantly base metal 100 1

D2752 Crown - porcelain fused to noble metal 1,200 5 D2780 Crown - 3/4 cast high noble metal 5 0

D2781 Crown - 3/4 cast predominantly base metal 1 0

D2782 Crown - 3/4 cast noble metal 3 0 D2783 Crown - 3/4 porcelain/ceramic 20 0 D2790 Crown - full cast high noble metal 4,000 16

D2791 Crown - full cast predominantly base metal 40 0

D2792 Crown - full cast noble metal 500 0 D2794 Crown - titanium 1 0

D2799 Provisional crown - further treatment or completion of diagnosis necessary prior to final impression 200 1

D2910 Recement inlay, onlay, or partial coverage restoration 15 1

D2915 Recement cast or prefabricated post and core 5 1

D2920 Recement crown 600 1

D2921 Reattachment of tooth fragment, incisal edge or cusp 5 0

D2929 Prefabricated porcelain/ceramic crown -primary tooth 1 0

D2930 Prefabricated stainless steel crown -primary tooth 1 0

D2931 Prefabricated stainless steel crown -permanent tooth 5 0

D2932 Prefabricated resin crown 5 3

D2933 Prefabricated stainless steel crown with resin window 1 0

D2940 Protective restoration 500 12

D2941 Interim therapeutic restoration - primary dentition 1 0

D2949 restorative foundation for an indirect restoration 5 0

D2950 Core buildup, including any pins when required 8,000 41

D2951 Pin retention - per tooth, in addition to restoration 100 0

D2952 Post and core in addition to crown, indirectly fabricated 200 13

D2953 Each additional indirectly fabricated post -same tooth 1 4

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D2954 Prefabricated post and core in addition to crown 1,500 17

D2955 Post removal (not in conjunction with endodontic therapy) 50 0

D2957 Each additional prefabricated post - same tooth 5 0

D2960 Labial veneer (resin laminate) - chairside 10 0

D2961 Labial veneer (resin laminate) -laboratory 5 0

D2962 Labial veneer (porcelain laminate) -laboratory 200 1

D2971 Additional procedures to construct new crown under existing partial denture framework 5 0

D2975 Coping 1 0

D2980 Crown repair, necessitated by restorative material failure 60 0

D2981 Inlay repair necessitated by restorative material failure 1 0

D2982 Onlay repair necessitated by restorative material failure 1 0

D2983 Veneer repair necessitated by restorative material failure 1 0

D2990 Resin infiltration of incipient smooth surface lesions 1 0

D2999 Unspecified restorative procedure, by report 10 5

D3110 Pulp cap - direct (excluding final restoration) 25 7

D3120 Pulp cap - indirect (excluding final restoration) 10 27

D3220

Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament 100 12

D3221 Pulpal debridement, primary and permanent teeth 200 5

D3222 Partial Pulpotomy for apexogenesis -permanent tooth with incomplete root development 1 0

D3230 Pulpal therapy (resorbable filling) -anterior, primary tooth (excluding final restoration) 1 0

D3240 Pulpal therapy (resorbable filling) -posterior, primary tooth excluding final restoration) 1 0

D3310 Endodontic therapy - anterior (excluding final restoration) 1,500 21

D3320 Endodontic therapy - bicuspid (excluding final restoration) 2,000 8

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D3330 Endodontic therapy - molar (excluding final restoration) 7,000 63

D3331 Treatment of root canal obstruction, non-surgical access 200 12

D3332 Incomplete endodontic therapy, inoperable, unrestorable or fractured tooth 150 0

D3333 Internal root repair of perforation defects 50 7

D3346 Retreatment of previous root canal therapy - anterior 300 4

D3347 Retreatment of previous root canal therapy - bicuspid 300 0

D3348 Retreatment of previous root canal therapy - molar 1,500 8

D3351

Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) 10 7

D3352 Apexification/recalcification - interim medication replacement 10 0

D3353

Apexification/recalcification - final visit (includes completed root canal therapy -apical closure/calcific repair of perforations, root resorption, etc.) 5 3

D3355 Pulpal regeneration - initial visit 5 0

D3356 Pupal regeneration - interim medication replacement 5 0

D3357 Pulpal regeneration - completion of treatment 5 0

D3410 Apicoectomy/periradicular surgery -anterior 200 0

D3421 Apicoectomy - bicuspid (first root) 50 0 D3425 Apicoectomy - molar (first root) 200 0 D3426 Apicoectomy (each additional root) 100 0

D3427 Periradicular surgery without apicoectomy 20 0

D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 10 0

D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 5 1

D3430 Retrograde filling - per root 400 53

D3431 Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery 5 0

D3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery 20 0

D3450 Root amputation - per root 10 4

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D3460 Endodontic endosseous implant 1 3

D3470 Intentional reimplantation (including necessary splinting) 1 0

D3910 Surgical procedure for isolation of tooth with rubber dam 50 1

D3920 Hemisection (including any root removal), not including root canal therapy 2 0

D3950 Canal preparation and fitting of preformed dowel or post 50 0

D3999 Unspecified endodontic procedure, by report 5 0

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant 30 1

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant 100 1

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth 50 0

D4230 Anatomical crown exposure - four or more contiguous teeth per quadrant 10 0

D4231 Anatomical crown exposure - one to three teeth per quadrant 10 1

D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant 50 0

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant 130 1

D4245 Apically positioned flap 10 0 D4249 Clinical crown lengthening - hard tissue 1,200 3

D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant 1,000 0

D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant 1,000 0

D4263 Bone replacement graft -retained natural tooth- first site in quadrant 1,200 3

D4264 Bone replacement graft - retained natural tooth-each additional site in quadrant 400 0

D4265 Biologic materials to aid in soft and osseous tissue regeneration 700 0

D4266 Guided tissue regeneration - resorbable barrier, per site 1,000 3

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D4267 Guided tissue regeneration -nonresorbable barrier, per site (includes membrane removal) 120 1

D4268 Surgical revision procedure, per tooth 10 0 D4270 Pedicle soft tissue graft procedure 200 0

D4271 Free soft tissue graft procedure (including donor site surgery) 1 0

D4273

Autogenous connective tissue graft procedure (including donor and recipient surgical sites)first tooth, implant or edentulous tooth position in graft 1,100 0

D4274

Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) 200 0

D4275

Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant or edentulous tooth position in graft 300 0

D4276 Combined connective tissue and double pedicle graft, per tooth 10 0

D4277

Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or dentulous tooth position in graft 200 0

D4278

Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or dentulous tooth position in same graft site 50 0

D4283

Autogenous connective tissue graft pocedure (including recipient surgical site and donor material) - each additional contguous tooth, implant or edentulous tooth position in same graft site 100 0

D4285

Non-autogenous connective tissue graft pocedure (including recipient surgical site and donor material) - each additional contguous tooth, implant or edentulous tooth position in same graft site 10 0

D4320 Provisional splinting - intracoronal 5 0 D4321 Provisional splinting - extracoronal 10 0

D4341 Periodontal scaling and root planing -four or more teeth per quadrant 15,000 89

D4342 Periodontal scaling and root planing - one to three teeth per quadrant 2,600 35

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D4346 Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation 100 0

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis 1,200 5

D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 150 0

D4910 Periodontal maintenance 9,000 15

D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) 2 3

D4921 Gingival irrigation - per quadrant 25 7

D4999 Unspecified periodontal procedure, by report 20 4

D5110 Complete denture - maxillary 50 0 D5120 Complete denture - mandibular 25 0 D5130 Immediate denture - maxillary 25 0 D5140 Immediate denture - mandibular 20 0

D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 30 0

D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth 20 0

D5213

Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 150 25

D5214

Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 150 16

D5221 Immediate maxillary partial denture -resin base(including any conventional clasps, rests and teeth 5 0

D5222 Immediate mandibular partial denture -resin base (including any conventional clasps, rests and teeth) 5 0

D5223

Immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth 5 0

D5224

Immediate mandibular partial denture -cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 5 0

D5225 Maxillary partial denture - flexible base (including any clasps, rests and teeth) 25 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D5226 Mandibular partial denture - flexible base (including any clasps, rests and teeth) 25 0

D5281 Removable unilateral partial denture -one piece cast metal (including clasps and teeth) 5 0

D5410 Adjust complete denture - maxillary 5 0 D5411 Adjust complete denture - mandibular 5 0 D5421 Adjust partial denture - maxillary 10 0 D5422 Adjust partial denture - mandibular 10 0

D5511 Repair broken complete denture base, mandibular 7 0

D5512 Repair broken complete denture base, maxillary 8 0

D5520 Replace missing or broken teeth -complete denture (each tooth) 10 1

D5611 Repair resin partial denture base, mandibular 15 0

D5612 Repair resin partial denture base, maxillary 15 0

D5621 Repair cast partial framework, mandibular 2 0

D5622 Repair cast partial framework maxillary 3 0

D5630 Repair or replace broken clasp - per tooth 5 0 D5640 Replace broken teeth - per tooth 20 0 D5650 Add tooth to existing partial denture 15 0

D5660 Add clasp to existing partial denture - per tooth 5 0

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 1 0

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 1 0

D5710 Rebase complete maxillary denture 5 0 D5711 Rebase complete mandibular denture 5 0 D5720 Rebase maxillary partial denture 2 0 D5721 Rebase mandibular partial denture 2 0

D5730 Reline complete maxillary denture (chairside) 5 0

D5731 Reline complete mandibular denture (chairside) 5 0

D5740 Reline maxillary partial denture (chairside) 5 0

D5741 Reline mandibular partial denture (chairside) 5 0

D5750 Reline complete maxillary denture (laboratory) 10 0

D5751 Reline complete mandibular denture (laboratory) 10 0

D5760 Reline maxillary partial denture (laboratory) 5 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D5761 Reline mandibular partial denture (laboratory) 5 0

D5810 Interim complete denture (maxillary) 15 0 D5811 Interim complete denture (mandibular) 10 0 D5820 Interim partial denture (maxillary) 220 0 D5821 Interim partial denture (mandibular) 40 3 D5850 Tissue conditioning, maxillary 10 0 D5851 Tissue conditioning, mandibular 10 0 D5862 Precision attachment, by report 30 0 D5863 Overdenture - complete maxillary 10 0 D5864 Overdenture - partial maxillary 5 0 D5865 Overdenture - complete mandibular 10 0 D5866 Overdenture - partial mandibular 5 0

D5867 Replacement of replaceable part of semi-precision or precision attachment ( male or female component) 10 0

D5875 Modification of removable prosthesis following implant surgery 3 3

D5899 Unspecified removable prosthodontic procedure, by report 5 0

D5911 Facial moulage (sectional) 1 0 D5912 Facial moulage (complete) 1 0 D5913 Nasal prosthesis 1 0 D5914 Auricular prosthesis 1 0 D5915 Orbital prosthesis 1 0 D5916 Ocular prosthesis 1 3 D5919 Facial prosthesis 1 0 D5922 Nasal septal prosthesis 1 0 D5923 Ocular prosthesis, interim 1 1 D5924 Cranial prosthesis 1 0 D5925 Facial augmentation implant prosthesis 1 0 D5926 Nasal prosthesis, replacement 1 0 D5927 Auricular prosthesis, replacement 1 0 D5928 Orbital prosthesis, replacement 1 0 D5929 Facial prosthesis, replacement 1 0 D5931 Oburator prosthesis, surgical 1 1 D5932 Obturator prosthesis, definitive 1 0 D5933 Obturator prosthesis, modification 1 0

D5934 Mandibular resection prosthesis with guide flange 1 0

D5935 Mandibular resection prosthesis without guide flange 1 0

D5936 Obturator prosthesis, interim 1 0

D5937 Trismus appliance (not for TMD treatment) 1 0

D5953 Speech aid prosthesis, adult 1 0 D5954 Palatal augmentation prosthesis 1 0 D5955 Palatal lift prosthesis, definitive 1 0 D5958 Palatal lift prosthesis, interim 1 0 D5959 Palatal lift prosthesis, modification 1 0 D5960 Speech aid prosthesis, modification 1 0 D5982 Surgical stent 150 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D5983 Radiation carrier 1 0 D5984 Radiation shield 1 0 D5985 Radiation cone locator 1 0 D5986 Fluoride gel carrier 10 0 D5987 Commissure splint 1 0 D5988 Surgical splint 10 0

D5991 Vesiculobullous disease medicament carrier 1 0

D5992 Adjust maxillofacial prosthetic appliance, by report 1 0

D5993

Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report 1 0

D5994 Periodontal medicament carrier with peripheral seal - laboratory processed 5 0

D5999 Unspecified maxillofacial prosthesis, by report 5 0

D6010 Surgical placement of implant body:

endosteal implant 2,000 9

D6011 Second stage implant surgery 500 0

D6012 Surgical placement of interim implant body for transitional prosthesis;

endosteal implant 2 1

D6013 Surgical placement of mini implant 5 0 D6040 Surgical placement: eposteal implant 5 0 D6050 Surgical placement: transosteal implant 1 0 D6051 Interim abutment 100 0 D6052 Semi-precision attachment abutment 5 0

D6053 Implant/abutment supported removable denture for completely edentulous arch 5 0

D6054 Implant/abutment supported removable denture for partially edentulous arch 5 0

D6055 Connecting bar - implant supported or abutment supported 10 0

D6056 Prefabricated abutment - includes modification and placement 300 1

D6057 Custom fabricated abutment - includes placement 1,100 1

D6058 Abutment supported porcelain/ceramic crown 500 5

D6059 Abutment supported porcelain fused to metal crown (high noble metal) 500 3

D6060 Abutment supported porcelain fused to metal crown ( predominantly base metal) 15 0

D6061 Abutment supported porcelain fused to metal crown (noble metal) 100 0

D6062 Abutment supported cast metal crown (high noble metal) 20 1

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D6063 Abutment supported cast metal crown (predominantly base metal) 1 0

D6064 Abutment supported cast metal crown (noble metal) 5 0

D6065 Implant supported porcelain/ceramic crown 100 0

D6066 Implant supported porcelain fused to metal crown (titanium alloy, high noble metal) 150 0

D6067 Implant supported metal crown 20 0

D6068 Abutment supported retainer for porcelain/ceramic FPD 10 0

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 40 0

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 10 0

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) 10 0

D6072 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 10 0

D6073 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 1 1

D6074 Abutment supported retainer for cast metal FPD (noble metal) 2 0

D6075 Implant supported retainer for ceramic

FPD 5 0

D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) 10 0

D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) 1 0

D6078 Implant/abutment supported fixed denture for completely edentulous arch 10 0

D6079 Implant/abutment supported fixed denture for partially edentulous arch 2 0

D6080

Implant maintenance procedures when prosthesis are removed and reinserted, including cleansing of prosthesis and abutments 50 0

D6081

Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure 80 0

D6085 Provisional implant crown 80 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D6090 Repair implant supported prosthesis, by report 5 0

D6091

Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment 10 0

D6092 Recement implant/abutment supported crown 10 0

D6093 Recement implant/abutment supported fixed partial denture 1 0

D6094 Abutment supported crown - (titanium) 5 0 D6095 Repair implant abutment, by report 10 0 D6096 Remove broken implant retaining screw 20 D6100 Implant removal, by report 45 0

D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure 10 0

D6102

Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure 15 0

D6103 Bone graft for repair of peri-implant defect - not including flap entry and closure 15 0

D6104 Bone graft at the time of implant placement 300 0

D6110 Implant/abutment supported removable denture for edentulous arch - maxillary 5 0

D6111 Implant/abutment supported removable denture for edentulous arch - mandibular 5 0

D6112 Implant/abutment supported removable denture for partially edentulous arch -maxillary 5 0

D6113 Implant/abutment supported removable denture for partially edentulous arch -mandibular 5 0

D6114 Implant/abutment supported fixed denture for edentulous arch - maxillary 5 0

D6115 Implant/abutment supported fixed denture for edentulous arch - mandibular 5 0

D6116 Implant/abutment supported fixed denture for partially edentulous arch -maxillary 5 0

D6117 Implant/abutment supported fixed denture for partially edentulous arch -mandibular 5 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D6118 Implant/abutment supported interim fixed denture for edentulous arch-mandibular 5 0

D6119 Implant/abutment supported interim fixed denture for edentulous arch-maxillary 5 0

D6190 Radiographic/surgical implant index, by report 200 0

D6194 Abutment supported retainer crown for FPD - (titanium) 1 0

D6199 Unspecified implant procedure, by report 20 0 D6205 Pontic - indirect resin based composite 1 25 D6210 Pontic - cast high noble metal 100 0 D6211 Pontic - cast predominantly base metal 5 0 D6212 Pontic - cast noble metal 10 0 D6214 Pontic - titanium 5 0

D6240 Pontic - porcelain fused to high noble metal 1,000 0

D6241 Pontic - porcelain fused to predominantly base metal 20 0

D6242 Pontic - porcelain fused to noble metal 200 0 D6245 Pontic - porcelain/ceramic 310 0 D6250 Pontic - resin with high noble metal 10 0

D6251 Pontic - resin with predominantly base metal 1 0

D6252 Pontic - resin with noble metal 3 0

D6253 Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression 40 4

D6545 Retainer - cast metal for resin bonded fixed prosthesis 25 0

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis 20 0

D6549 Resin retainer - for resin bonded fixed prosthesis 5 0

D6600 Retainer inlay - porcelain/ceramic, two surfaces 1 0

D6601 Retainer inlay - porcelain/ceramic, three or more surfaces 2 0

D6602 Retainer inlay - cast high noble metal, two surfaces 5 0

D6603 Retainer inlay - cast high noble metal, three or more surfaces 5 0

D6604 Retainer inlay - cast predominantly base metal, two surfaces 1 0

D6605 Retainer inlay - cast predominantly base metal, three or more surfaces 1 0

D6606 Retainer inlay - cast noble metal, two surfaces 1 1

D6607 Retainer inlay -cast noble metal, three or more surfaces 1 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D6608 Retainer onlay - porcelain/ceramic, two surfaces 1 0

D6609 Retainer onlay - porcelain/ceramic, three or more surfaces 5 0

D6610 Retainer onlay - cast high noble metal, two surfaces 1 0

D6611 Retainer onlay - cast high noble metal, three or more surfaces 5 0

D6612 Retainer onlay - cast predominantly base metal, two surfaces 1 0

D6613 Retainer onlay - cast predominantly base metal, three or more surfaces 1 0

D6614 Retainer onlay - cast noble metal, two surfaces 1 0

D6615 Retainer onlay - cast noble metal, three or more surfaces 1 0

D6624 Retainer inlay - titanium 1 0 D6634 Retainer onlay - titanium 1 0

D6710 Retainer crown - indirect resin based composite 1 0

D6720 Retainer crown - resin with high noble metal 5 0

D6721 Retainer crown - resin with predominantly base metal 5 0

D6722 Retainer crown - resin with noble metal 2 0 D6740 Retainer crown - porcelain/ceramic 450 15

D6750 Retainer crown - porcelain fused to high noble metal 1,500 0

D6751 Retainer crown - porcelain fused to predominantly base metal 20 1

D6752 Retainer crown - porcelain fused to noble metal 300 0

D6780 Retainer crown - 3/4 cast high noble metal 20 0

D6781 Retainer crown - 3/4 cast predominantly base metal 1 0

D6782 Retainer crown - 3/4 cast noble metal 1 0 D6783 Retainer crown - 3/4 porcelain/ceramic 3 0

D6790 Retainer crown - full cast high noble metal 200 1

D6791 Retainer crown - full cast predominantly base metal 2 0

D6792 Retainer crown - full cast noble metal 65 0

D6793 Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression 50 0

D6794 Retainer crown - titanium 1 0 D6920 Connector Bar 1 0 D6930 Recement fixed partial denture 40 0 D6940 Stress breaker 10 0 D6950 Precision attachment 10 0 D6975 Coping 5 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D6980 Fixed partial denture repair, necessitated by restorative material failure 5 0

D6999 Unspecified fixed prosthodontic procedure, by report 10 3

D7111 Extraction, coronal remnants - deciduous tooth 10 3

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) 5,000 39

D7210

Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 16,000 16

D7220 Removal of impacted tooth - soft tissue 4,000 3

D7230 Removal of impacted tooth - partially bony 15,000 1

D7240 Removal of impacted tooth - completely bony 18,000 1

D7241 Removal of impacted tooth - completely bony, with unusual surgical complications 1,500 0

D7250 Removal of residual tooth roots (cutting procedure) 200 4

D7251 Coronectomy 50 0 D7260 Oroantral fistula closure 20 0 D7261 Primary closure of a sinus perforation 125 0

D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth 20 0

D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and / or stabilization) 1 0

D7280 Exposure of an unerupted tooth 20 0

D7282 Mobilization of erupted or malpositioned tooth to aid eruption 2 0

D7283 Placement of device to facilitate eruption of impacted tooth 20 0

D7285 Biopsy of oral tissue - hard (bone, tooth) 70 0 D7286 Biopsy of oral tissue - soft 350 0

D7287 Exfoliative cytological sample collection 1 0

D7288 Brush biopsy - transepithelial sample collection 5 0

D7290 Surgical repositioning of teeth 2 0

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report 5 0

D7292 Placement: temporary anchorage device [screw retained plate] requiring surgical flap 10 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D7293 Placement: temporary anchorage device requiring surgical flap 2 0

D7294 Placement: temporary anchorage device without surgical flap 5 0

D7295 Harvest of bone for use in autogenous grafting procedure 10 0

D7296 Corticotomy - one to three teeth or tooth spaces, per quadrant 1 0

D7297 Cortocotomy - fourt or more teeth or tooth spaces, per quadrant 1 0

D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces per quadrant 20 0

D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces per quadrant 20 0

D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces per quadrant 10 0

D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces per quadrant 15 0

D7340 Vestibuloplasty - ridge extension (secondary epithelialization) 2 0

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) 10 0

D7410 Excision of benign lesion up to 1.25 cm 150 0

D7411 Excision of benign lesion greater than

1.25 cm 40 0

D7412 Excision of benign lesion, complicated 15 0

D7413 Excision of malignant lesion up to 1.25 cm 1 0

D7414 Excision of malignant lesion greater than

1.25 cm 1 0

D7415 Excision of malignant lesion, complicated 1 0

D7440 Excision of malignant tumor - lesion diameter up to 1.25 cm 3 0

D7441 Excision of malignant tumor - lesion diameter greater than 1.25 cm 3 0

D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm 50 0

D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm 25 0

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm 10 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than

1.25 cm 15 0

D7465 Destruction of lesion(s) by physical or chemical method, by report 15 0

D7471 Removal of lateral exostosis (maxilla or mandible) 25 0

D7472 Removal of torus palatinus 5 0 D7473 Removal of torus mandibularis 50 0 D7485 Reduction of osseous tuberosity 5 0

D7490 Radical resection of maxilla or mandible 2 0

D7510 Incision and drainage of abscess -intraoral soft tissue 125 3

D7511

Incision and drainage of abscess -intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) 20 0

D7520 Incision and drainage of abscess -extraoral soft tissue 5 0

D7521

Incision and drainage of abscess -extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) 5 0

D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue 20 0

D7540 Removal of reaction producing foreign bodies, musculoskeletal system 20 0

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone 30 0

D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body 10 0

D7610 Maxilla - open reduction (teeth immobilized, if present) 1 0

D7620 Maxilla - closed reduction (teeth immobilized, if present) 1 0

D7630 Mandible - open reduction (teeth immobilized, if present) 2 0

D7640 Mandible - closed reduction (teeth immobilized, if present) 5 0

D7650 Malar and/or zygomatic arch - open reduction 1 0

D7660 Malar and/or zygomatic arch - closed reduction 1 0

D7670 Alveolus - closed reduction, may include stabilization of teeth 5 0

D7671 Alveolus - open reduction, may include stabilization of teeth 1 0

D7680 Facial bones - complicated reduction with fixation and multiple surgical approaches 1 0

D7710 Maxilla open reduction 1 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D7720 Maxilla - closed reduction 1 0 D7730 Mandible - open reduction 3 0 D7740 Mandible - closed reduction 5 0

D7750 Malar and/or zygomatic arch - open reduction 1 0

D7760 Malar and/or zygomatic arch - closed reduction 1 0

D7770 Alveolus - open reduction stabilization of teeth 1 0

D7771 Alveolus - closed reduction stabilization of teeth 5 0

D7780 Facial bones - complicated reduction with fixation and multiple approaches 1 0

D7810 Open reduction of dislocation 2 0 D7820 Closed reduction of dislocation 5 0 D7830 Manipulation under anesthesia 5 0 D7840 Condylectomy 1 0

D7850 Surgical discectomy, with/without implant 1 0

D7852 Disc repair 1 0 D7854 Synovectomy 1 0 D7856 Myotomy 1 0 D7858 Joint reconstruction 1 0 D7860 Arthrotomy 1 0 D7865 Arthroplasty 1 0 D7870 Arthrocentesis 15 0 D7871 Non-arthroscopic lysis and lavage 10 0

D7872 Arthroscopy - diagnosis with or without biopsy 1 0

D7873 Arthroscopy: lavage and lysis of adhesions 1 0

D7874 Arthroscopy: disc repositioning and stabilization 1 0

D7875 Arthroscopy: synovectomy 1 0 D7876 Arthroscopy: discectomy 1 0 D7877 Arthroscopy: debridement 1 0 D7880 Occlusal orthotic device, by report 25 1 D7881 Occlusal orthotic device adjustment 1 0 D7899 Unspecified TMD therapy, by report 5 0

D7910 Suture of recent small wounds up to 5 cm 5 3 D7911 Complicated suture - up to 5 cm 5 1 D7912 Complicated suture - greater than 5 cm 3 0

D7920 Skin graft (identify defect covered, location, and type of graft) 1 0

D7921 Collection and application of autologous blood concentrate product 200 0

D7940 Osteoplasty - orthognathic deformities 1 0 D7941 Osteotomy - mandibular rami 1 0

D7943 Osteotomy - mandibular rami with bone fraft; includes obtaining the graft 2 0

D7944 Osteotomy - segmented or subapical 1 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D7945 Osteotomy - body of mandible 1 0 D7946 LeFort I (maxilla - total) 1 0 D7947 LeFort I (maxilla - segmented) 1 0

D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft 1 0

D7949 LeFort II or LeFort III with bone graft 1 0

D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla -autogenous or nonautogenous, by report 300 0

D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach 100 0

D7952

Sinus augmentation via a vertical approach - the augmentation of the sinus to increase alveolar height by vertical access through the ridge crest by raising the floor of the sinus and grafting as necessary - this includes obtaining the bone or bone substitutes 30 0

D7953 Bone replacement graft for ridge preservation - per site 900 1

D7955 Repair of maxillofacial soft and/or hard tissue defect 30 0

D7960 Frenulectomy ( also know as frenectomy or frenotomy) - separate procedure not incidental to another 175 0

D7963 Frenuloplasty 5 0 D7970 Excision of hyperplastic tissue - per arch 5 0 D7971 Excision of pericoronal gingiva 15 0 D7972 Surgical reduction of fibrous tuberosity 5 0 D7979 Non-surgical sialolithotomy 20 0 D7980 Sialolithotomy 10 0 D7981 Excision of salivary gland, by report 5 0 D7982 Sialodochoplasty 10 0 D7983 Closure of salivary fistula 1 0 D7990 Emergency tracheotomy 1 0 D7991 Coronoidectomy 1 0

D7995 Synthetic graft - mandible or facial bones, by report 25 0

D7996 Implant - mandible for augmentation purposes (excluding alveolar ridge), by report 1 0

D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar 10 0

D7998 Intraoral placement of a fixation device not in conjunction with a fracture 2 0

D7999 Unspecified oral surgery procedure, by report 10 4

D8040 Limited orthodontic treatment of the adult dentition 5 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D8090 Comprehensive orthodontic treatment of the adult dentition 200 0

D8210 Removable appliance therapy (an example would be for treating tongue thrusting) 1 0

D8220 Fixed applaince therapy 1 0 D8660 Pre-orthodontic treatment visit 60 0

D8670 Periodic orthodontic treatment visit (as part of contract) 800 0

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 150 1

D8681 Removable orthodontic retainer adjustment 1 0

D8690 Orthodontic treatment (alternative billing to a contract fee) 1 0

D8691 Repair of orthodontic appliance 2 0 D8692 Replacement of lost or broken retainer 10 0

D8693 Rebonding or recementing of fixed retainers 5 0

D8694 repair of fixed retainers, includes reattachment 5 0

D8695 Removal of fixed orthodontic appliances for reasons other than completion of treatment 5 0

D8999 Unspecified orthodontic procedure, by report 5 0

D9110 Palliative (emergency) treatment of dental pain - minor procedure 1,200 15

D9120 Fixed partial denture sectioning 10 0

D9210 Local anesthesia not in conjunction with operative or surgical procedures 10 3

D9211 Regional block anesthesia 10 0 D9212 Trigeminal division block anesthesia 1 0

D9215 Local anesthesia in conjunctin with operative or surgical procedures 10 3

D9219 evaluation for deep sedation or general anesthesia 5 0

D9222 Deep sedation/general anesthesia - first 15 minutes 2,000 0

D9223 Deep sedation/general anesthesia - each 15 minute increment 18,000 0

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis 1,000 5

D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes 2,500 0

D9243 Intravenous moderate (conscious) sedation/analgesia - each 15 minute increment 9,000 0

D9248 Non-intravenous (conscious) sedation 300 3

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 7,000 25

D9311 consultation with a medical health care professioinal 5 0

D9410 House / extended care facility call 1 0

D9420 Hospital or ambulatory surgical center call 10 0

D9430 Office visit for observation (during regularly scheduled hours) - no other services performed 5 0

D9440 Office visit - after regularly scheduled hours 50 0

D9450 Case presentation, detailed and extensive treatment planning 5 0

D9610 Therapeutic parenteral drug, single administration 3,000 0

D9612 Therapeutic parenteral drugs, two or more administrations, different medications 2,200 0

D9630 Drugs or medicaments dispensed in the office for home use 500 1

D9910 Application of desensitizing medicament 900 69

D9911 Application of desensitizing resin for cervical and/or root surface, per tooth 10 0

D9920 Behavior management, by report 10 0

D9930 Treatment of complications - unusual circumstances, by report 60 1

D9932 Cleaning and inspection of removable complete denture, maxillary 1 0

D9933 Cleaning and inspection of removable complete denture, mandibular 1 0

D9934 Cleaning and inspection of removable partial denture, maxillary 1 0

D9935 Cleaning and inspection of removable partial denture, mandibular 1 0

D9940 Occlusal guard, by report 2,600 25 D9941 Fabrication of athletic mouthguard 150 0 D9942 Repair and/or reline of occlusal guard 5 0 D9943 Occlusal guard adjustment 5 0 D9950 Occlusion analysis - mounted case 125 0 D9951 Occlusal adjustment - limited 125 7 D9952 Occlusal adjustment - complete 50 1 D9970 Enamel microabrasion 10 0

D9971 Odontoplasty 1-2 teeth, includes removal of enamel projections 50 0

D9972 External bleaching - per arch - performed in office 10 1

D9973 External bleaching - per tooth 3 0 D9974 Internal bleaching - per tooth 50 0

Exhibit A: 2018 CDT Pricing Table for ADSMs

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-R-0001

Procedure Code Description

Estimated

CONUS

Quantity (Annual)

Estimated

OCONUS

Quantity (Annual)

D9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays 1 0

D9986 Missed appointment 1 0 D9987 Cancelled appointment 1 0

D9991 Dental case management-addressing appointment compliance barriers 1 0

D9992 Dental case management-care coordination 1 0

D9993 Dental case management-motivational interviewing 1 0

D9994 Dental case management-patient education to improve oral health literacy 1 0

D9995 Teledentistry - synchronous; real-time encounter 1 0

D9996 Teledentistry - asynchronous;

information stored and forwarded to dentist for subsequent review 1 0

D9999 Unspecified adjunctive procedure, by report 150 11

Grand Total 750,645 5,208

Exhibit B: 2018 CDT Pricing Table for Selected Reserve and

TRICARE DENTAL READINESS AND WELLNESS - HT9402-17-

CDT codes marked by an asterisk are normally considered for use when plan Other CDT codes may be required to be used to correct a patient's Dental Re

Procedure Code Description

Estimated Quantity (Annual)

D0120* Periodic oral evaluation - established patient 176,927

D0140* Limited oral evaluation - problem focused 23,420

D0150* Comprehensive oral evaluation - new or established patient 202,213

D0160* Detailed and extensive…