ADDP3 Exhibit A -CDT Price List 2020.xlsx

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Attached to
Active Duty Dental Program 3 (ADDP3) Federal contract opportunity
Solicitation number
HT9402-20-R-0001
Issued by
Defense Health Agency

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This document contains an exhibit listing estimated pricing for dental procedures under the Active Duty Dental Program 3 (ADDP3) contract. The ADDP3 is a requirements contract to provide dental services, claims processing, and associated customer support for TRICARE Active Duty Service Members in the continental United States. The exhibit lists dental procedure codes, estimated quantities, unit prices, and extended prices for each option period of performance. Key details include over 500 dental procedure line items with estimated annual volumes and unit pricing for a potential seven-year ordering period. The Defense Health Agency is the contracting agency for this continuing dental care program serving Active Duty Service Members.

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HT940220R0001 Amend 0002.pdf PDF
HT9402-20-R-0001 Amend 0001 Final.pdf PDF
ADDP3 RFP Question and Answer.docx DOCX document
ADDP3 J Attch Final.zip ZIP file
HT9402-20-R-0001 Final.pdf PDF
ADDP3 Exhibit B CDRLs Final.zip ZIP file

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Exhibit A

Exhibit A - CONUS
TRICARE ACTIVE DUTY DENTAL PROGRAM - HT9402-20-R-0001 - CDT PRICING TABLE - 2020 codes
Option Period 1Option Period 2Option Period 3Option Period 4Option Period 5Option Period 6Option Period 7Estimated Total Price
Procedure CodeDescriptionEstimated QuantityUnit PriceExtended PriceEstimated QuantityUnit PriceExtended PriceEstimated QuantityUnit PriceExtended PriceEstimated QuantityUnit PriceExtended PriceEstimated QuantityUnit PriceExtended PriceEstimated QuantityUnit PriceExtended PriceEstimated QuantityUnit PriceExtended Price
D0120Periodic oral evaluation - established patient61,000$ - 061,300$ - 061,400$ - 061,500$ - 061,500$ - 061,500$ - 061,500$ - 0$ - 0
D0140Limited oral evaluation - problem focused62,200$ - 065,100$ - 066,600$ - 067,600$ - 067,600$ - 067,600$ - 067,600$ - 0$ - 0
D0150Comprehensive oral evaluation - new or established patient37,300$ - 039,000$ - 039,900$ - 040,500$ - 040,500$ - 040,500$ - 040,500$ - 0$ - 0
D0160Detailed and extensive oral evaluation - problem focused, by report900$ - 01,000$ - 01,000$ - 01,000$ - 01,000$ - 01,000$ - 01,000$ - 0$ - 0
D0170Re-evaluation - limited, problem focused (established patient, not post-operative visit)400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0$ - 0
D0171Re-evaluation - post-operative office visit50$ - 060$ - 060$ - 060$ - 060$ - 060$ - 060$ - 0$ - 0
D0180Comprehensive periodontal evaluation - new or established patient2,400$ - 02,400$ - 02,500$ - 02,500$ - 02,500$ - 02,500$ - 02,500$ - 0$ - 0
D0190Screening of a patient1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0191Assessment of a patient1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0210Intraoral - complete series of radiographic images18,300$ - 019,000$ - 019,300$ - 019,600$ - 019,600$ - 019,600$ - 019,600$ - 0$ - 0
D0220Intraoral - periapical first radiographic image49,900$ - 051,800$ - 052,800$ - 053,500$ - 053,500$ - 053,500$ - 053,500$ - 0$ - 0
D0230Intraoral - periapical each additional radiographic image38,500$ - 040,300$ - 041,200$ - 041,900$ - 041,900$ - 041,900$ - 041,900$ - 0$ - 0
D0240Intraoral - occlusal radiographic image200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D0250Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
DO251Extraoral posterior dental radiographic image5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D0270Bitewing - single radiographic image4,600$ - 04,800$ - 04,900$ - 05,000$ - 05,000$ - 05,000$ - 05,000$ - 0$ - 0
D0272Bitewings - two radiographic images5,300$ - 05,600$ - 05,700$ - 05,800$ - 05,800$ - 05,800$ - 05,800$ - 0$ - 0
D0273Bitewings - three radiographic images300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0$ - 0
D0274Bitewings - four radiographic images55,200$ - 057,400$ - 058,500$ - 059,300$ - 059,300$ - 059,300$ - 059,300$ - 0$ - 0
D0277Vertical bitewings - 7 to 8 radiographic images300$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0$ - 0
D0310Sialography1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0320Temporomandibular joint arthrogram, including injection1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0321Other temporomandibular joint radiographic images, by report2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D0322Tomographic survey100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D0330Panoramic radiographic image29,700$ - 031,100$ - 031,800$ - 032,300$ - 032,300$ - 032,300$ - 032,300$ - 0$ - 0
D03402D cephalometric radiographic image - acquisition, measurement and analysis100$ - 0100$ - 0100$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D0350Oral/facial photographic image obtained intraorally or extraorally500$ - 0500$ - 0500$ - 0600$ - 0600$ - 0600$ - 0600$ - 0$ - 0
D03513D photographic image50$ - 050$ - 050$ - 050$ - 050$ - 050$ - 050$ - 0$ - 0
D0364Cone beam CT capture and interpretation with limited field of view - less than one whole jaw3,700$ - 03,900$ - 04,000$ - 04,000$ - 04,000$ - 04,000$ - 04,000$ - 0$ - 0
D0365Cone beam CT capture and interpretation with limited field of view of one full dental arch - mandible600$ - 0600$ - 0600$ - 0600$ - 0600$ - 0600$ - 0600$ - 0$ - 0
D0366Cone beam CT capture and interpretation with limited field of view of one full dental arch - maxilla, with or without cranium400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0$ - 0
D0367Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium2,000$ - 02,100$ - 02,100$ - 02,200$ - 02,200$ - 02,200$ - 02,200$ - 0$ - 0
D0368Cone beam CT capture and interpretation for TMJ series including two or more exposures20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D0369Maxillofacial MRI capture and interpretation1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0370Maxillofacial ultrasound capture and interpretation1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0371Sialoendoscopy capture and interpretation1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0380Cone beam CT image capture with limited field of view - less than one whole jaw700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0$ - 0
D0381Cone beam CT image capture with limited field of view of one full dental arch - mandible50$ - 050$ - 050$ - 050$ - 050$ - 050$ - 050$ - 0$ - 0
D0382Cone beam CT imagae capture with limited field of view of one full dental arch - maxilla, with or without cranium40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D0383Cone beam CT image capture with field of view of both jaws, with or without cranium500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D0384Cone beam CT image capture for TMJ series including two or more exposures2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D0385Maxillofacial MRI image capture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0386Maxillofacial ultrasound image capture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0391Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report50$ - 050$ - 050$ - 050$ - 050$ - 050$ - 050$ - 0$ - 0
D0393Treatment simulation using 3D image volume100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D0394Digital subtraction of two or more images or image volumes of the same modality1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0395Fusion of two or more 3D image volumes of one or more modalities40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D0411HbA1c in-office point of service testing1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0412Blood glucose level test - in-office using a glucose meter1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0414Laboratory processing of microbial speciment to include culture and sensitivity studies, preparation and transmission of written report2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D0415Collection of microorganisms for culture and sensitivity2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D0416Viral culture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0417Collection and preparation of saliva sample for laboratory diagnostic testing1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0418Analysis of saliva sample1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0419Assessment of salivary flow by measurement1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0422Collection and preparation of genetic sample material for laboratory anlysis and report1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0423Genetic test for susceptibility to deseasees - specimen analysis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0425Caries susceptibility tests1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0431Adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures70$ - 070$ - 070$ - 070$ - 070$ - 070$ - 070$ - 0$ - 0
D0460Pulp vitality tests100$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D0470Diagnostic casts500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D0472Accession of tissue, gross examination preparation and transmission of written report1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0473Accession of tissue, gross and microscopic examination, preparation and transmission of written report6$ - 06$ - 07$ - 07$ - 07$ - 07$ - 07$ - 0$ - 0
D0474Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D0475Decalcification procedure1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0476Special stains for microorganisms1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0477Special stains, not for microorganisms1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0478Imminohistochemical stains1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0479Tissue in-situ hybridization, including interpretation1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0480Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0481Electron microscopy - diagnostic1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0482Direct immunofluorescence1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0483Indirect immunofluorescence1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0484Consultation on slides prepared elsewhere1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0485Consultation, including preparation of slides from biopsy material supplied by referring source1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0486Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0502Other oral pathology procedures, by report1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0600Non-ionizingdiagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0601Caries risk assessment and documentation, with a finding of low risk1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0602Caries risk assessment and documentation, with a finding of moderate risk1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0603Caries risk assessment and documentation, with a finding of high risk1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D0999Unspecified diagnostic procedure, by report2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D1110Prophylaxis - adult111,600$ - 0115,600$ - 0117,600$ - 0119,000$ - 0119,000$ - 0119,000$ - 0119,000$ - 0$ - 0
D1206Topical application of fluoride varnish37,000$ - 038,700$ - 039,600$ - 040,200$ - 040,200$ - 040,200$ - 040,200$ - 0$ - 0
D1208Topical application of fluoride15,300$ - 015,300$ - 015,300$ - 015,300$ - 015,300$ - 015,300$ - 015,300$ - 0$ - 0
D1310Nutritional counseling for control of dental disease1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1320Tobacco counseling for the control and prevention of oral disease1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1330Oral hygiene instructions40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D1351Sealant - per tooth1,100$ - 01,100$ - 01,100$ - 01,100$ - 01,100$ - 01,100$ - 01,100$ - 0$ - 0
D1352Preventive resin restoration in a moderate to high caries risk patient - permanent tooth100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D1353Sealant repair - per tooth1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1354Interim caries arresting medicament appplication-per tooth2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D1510Space maintainer - fixed - unilateral - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1516Space maintainer - fixed - bilateral, maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1517Space maintainer - fixed - bilateral, mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1520Space maintainer - removable - unilateral - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1526Space maintainer - removable - bilateral, maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1527Space maintainer - removable - bilateral, mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1551Re-cement or re-bond bilateral space maintainer - maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1552Re-cement or re-bond bilateral space maintainer - mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1553Re-cement or re-bond unilateral space maintainer - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1556Removal of fixed unilateral space maintainer - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1557Removal of fixed bilateral space maintainer - maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1558Removal of fixed bilateral space maintainer - mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1575Distal shoe space maintainer-fixed-unilateral - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D1999Unspecified preventive procedure, by report480,000$ - 0480,200$ - 0480,300$ - 0480,400$ - 0480,500$ - 0480,500$ - 0480,500$ - 0$ - 0
D2140Amalgam - one surface, primary or permanent4,800$ - 05,000$ - 05,100$ - 05,200$ - 05,200$ - 05,200$ - 05,200$ - 0$ - 0
D2150Amalgam - two surfaces, primary or permanent9,700$ - 010,100$ - 010,400$ - 010,500$ - 010,500$ - 010,500$ - 010,500$ - 0$ - 0
D2160Amalgam - three surfaces, primary or permanent3,700$ - 03,900$ - 04,000$ - 04,000$ - 04,000$ - 04,000$ - 04,000$ - 0$ - 0
D2161Amalgam - four or more surfaces, primary or permanent900$ - 0900$ - 0900$ - 0900$ - 0900$ - 0900$ - 0900$ - 0$ - 0
D2330Resin-based composite - one surface, anterior5,300$ - 05,600$ - 05,700$ - 05,800$ - 05,800$ - 05,800$ - 05,800$ - 0$ - 0
D2331Resin-based composite - two surfaces, anterior6,800$ - 07,100$ - 07,300$ - 07,400$ - 07,400$ - 07,400$ - 07,400$ - 0$ - 0
D2332Resin-based composite - three surfaces, anterior4,500$ - 04,700$ - 04,800$ - 04,900$ - 04,900$ - 04,900$ - 04,900$ - 0$ - 0
D2335Resin-based composite - four or more surfaces or involving incisal angle (anterior)3,000$ - 03,200$ - 03,300$ - 03,300$ - 03,300$ - 03,300$ - 03,300$ - 0$ - 0
D2390Resin-based composite crown, anterior1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2391Resin-based composite - one surface, posterior25,600$ - 026,800$ - 027,400$ - 027,800$ - 027,800$ - 027,800$ - 027,800$ - 0$ - 0
D2392Resin-based composite - two surfaces, posterior38,100$ - 039,900$ - 040,800$ - 041,400$ - 041,400$ - 041,400$ - 041,400$ - 0$ - 0
D2393Resin-based composite - three surfaces, posterior13,900$ - 014,500$ - 014,800$ - 015,100$ - 015,100$ - 015,100$ - 015,100$ - 0$ - 0
D2394Resin-based composite - four or more surfaces, posterior2,600$ - 02,800$ - 02,800$ - 02,900$ - 02,900$ - 02,900$ - 02,900$ - 0$ - 0
D2410Gold foil - one surface1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2420Gold foil - two surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2430Gold foil - three surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2510Inlay - metallic - one surface1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2520Inlay - metallic - two surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2530Inlay - metallic - three or more surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2542Onlay - metallic - two surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2543Onlay - metallic - three surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2544Onlay - metallic - four or more surfaces2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D2610Inlay - porcelain/ceramic - one surface1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2620Inlay - porcelain/ceramic - two surfaces20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D2630Inlay - porcelain/ceramic - three or more surfaces10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D2642Onlay - porcelain/ceramic - two surfaces5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D2643Onlay - porcelain/ceramic - three surfaces30$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D2644Onlay - porcelain/ceramic - four or more surfaces30$ - 030$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D2650Inlay - resin-based composite - one surface1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2651Inlay - resin-based composite - two surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2652Inlay - resin-based composite - three or more surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2662Onlay - resin-based composite - two surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2663Onlay - resin-based composite - three surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2664Onlay - resin-based composite - four or more surfaces1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2710Crown - resin - based composite (indirect)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2712Crown - 3/4 resin-based composite (indirect)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2720Crown - resin with high noble metal1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2721Crown - resin with predominantly base metal1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2722Crown - resin with noble metal1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2740Crown - porcelain/ceramic13,300$ - 013,900$ - 014,200$ - 014,400$ - 014,400$ - 014,400$ - 014,400$ - 0$ - 0
D2750Crown - porcelain fused to high noble metal3,200$ - 03,200$ - 03,200$ - 03,200$ - 03,200$ - 03,200$ - 03,200$ - 0$ - 0
D2751Crown - porcelain fused to predominantly base metal40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D2752Crown - porcelain fused to noble metal500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D2753Crown - porcelain fused to titanium and titanium alloys1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2780Crown - 3/4 cast high noble metal6$ - 06$ - 07$ - 07$ - 07$ - 07$ - 07$ - 0$ - 0
D2781Crown - 3/4 cast predominantly base metal1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2782Crown - 3/4 cast noble metal1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2783Crown - 3/4 porcelain/ceramic5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D2790Crown - full cast high noble metal1,600$ - 01,600$ - 01,600$ - 01,600$ - 01,600$ - 01,600$ - 01,600$ - 0$ - 0
D2791Crown - full cast predominantly base metal5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D2792Crown - full cast noble metal200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D2794Crown - titanium and titanium alloys1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2799Provisional crown - further treatment or completion of diagnosis necessary prior to final impression200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D2910Recement inlay, onlay, or partial coverage restoration10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D2915Recement cast or prefabricated post and core1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2920Recement crown600$ - 0600$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0$ - 0
D2921Reattachment of tooth fragment, incisal edge or cusp4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D2929Prefabricated porcelain/ceramic crown - primary tooth1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2930Prefabricated stainless steel crown - primary tooth1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2931Prefabricated stainless steel crown - permanent tooth2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D2932Prefabricated resin crown1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2933Prefabricated stainless steel crown with resin window1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2940Protective restoration500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D2941Interim therapeutic restoration - primary dentition1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2949Restorative foundation for an indirect restoration1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2950Core buildup, including any pins when required10,700$ - 011,200$ - 011,500$ - 011,600$ - 011,600$ - 011,600$ - 011,600$ - 0$ - 0
D2951Pin retention - per tooth, in addition to restoration80$ - 090$ - 090$ - 090$ - 090$ - 090$ - 090$ - 0$ - 0
D2952Post and core in addition to crown, indirectly fabricated300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0$ - 0
D2953Each additional indirectly fabricated post - same tooth2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D2954Prefabricated post and core in addition to crown1,100$ - 01,100$ - 01,100$ - 01,100$ - 01,100$ - 01,100$ - 01,100$ - 0$ - 0
D2955Post removal (not in conjunction with endodontic therapy)50$ - 060$ - 060$ - 060$ - 060$ - 060$ - 060$ - 0$ - 0
D2957Each additional prefabricated post - same tooth1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2960Labial veneer (resin laminate) - chairside3$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D2961Labial veneer (resin laminate) - laboratory2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D2962Labial veneer (porcelain laminate) - laboratory200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D2971Additional procedures to construct new crown under existing partial denture framework1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2975Coping1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2980Crown repair, necessitated by restorative material failure60$ - 060$ - 060$ - 060$ - 060$ - 060$ - 060$ - 0$ - 0
D2981Inlay repair necessitated by restorative material failure1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2982Onlay repair necessitated by restorative material failure1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2983Veneer repair necessitated by restorative material failure1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2990Resin infiltration of incipient smooth surface lesions1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D2999Unspecified restorative procedure, by report8$ - 08$ - 08$ - 08$ - 08$ - 08$ - 08$ - 0$ - 0
D3110Pulp cap - direct (excluding final restoration)700$ - 0700$ - 0800$ - 0800$ - 0800$ - 0800$ - 0800$ - 0$ - 0
D3120Pulp cap - indirect (excluding final restoration)20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D3220Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament70$ - 070$ - 080$ - 080$ - 080$ - 080$ - 080$ - 0$ - 0
D3221Pulpal debridement, primary and permanent teeth300$ - 0300$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0$ - 0
D3222Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3230Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3240Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3310Endodontic therapy - anterior (excluding final restoration)1,500$ - 01,600$ - 01,600$ - 01,600$ - 01,600$ - 01,600$ - 01,600$ - 0$ - 0
D3320Endodontic therapy - premolar (excluding final restoration)2,200$ - 02,300$ - 02,300$ - 02,400$ - 02,400$ - 02,400$ - 02,400$ - 0$ - 0
D3330Endodontic therapy - molar tooth (excluding final restoration)7,400$ - 07,600$ - 07,800$ - 07,900$ - 07,900$ - 07,900$ - 07,900$ - 0$ - 0
D3331Treatment of root canal obstruction, non-surgical access300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0$ - 0
D3332Incomplete endodontic therapy, inoperable, unrestorable or fractured tooth100$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D3333Internal root repair of perforation defects50$ - 050$ - 050$ - 050$ - 050$ - 050$ - 050$ - 0$ - 0
D3346Retreatment of previous root canal therapy - anterior400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0400$ - 0$ - 0
D3347Retreatment of previous root canal therapy - premolar200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D3348Retreatment of previous root canal therapy - molar1,400$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 0$ - 0
D3351Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)6$ - 06$ - 07$ - 07$ - 07$ - 07$ - 07$ - 0$ - 0
D3352Apexification/recalcification - interim medication replacement6$ - 06$ - 07$ - 07$ - 07$ - 07$ - 07$ - 0$ - 0
D3353Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)7$ - 08$ - 08$ - 08$ - 08$ - 08$ - 08$ - 0$ - 0
D3355Pulpal regeneration - initial visit1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3356Pupal regeneration - interim medication replacement1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3357Pulpal regeneration - completion of treatment1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3410Apicoectomy/periradicular surgery - anterior200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D3421Apicoectomy - premolar (first root)60$ - 070$ - 070$ - 070$ - 070$ - 070$ - 070$ - 0$ - 0
D3425Apicoectomy - molar (first root)200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D3426Apicoectomy (each additional root)100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D3427Periradicular surgery without apicoectomy9$ - 09$ - 09$ - 09$ - 09$ - 09$ - 09$ - 0$ - 0
D3428Bone graft in conjunction with periradicular surgery - per tooth, single site100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D3429Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site7$ - 08$ - 08$ - 08$ - 08$ - 08$ - 08$ - 0$ - 0
D3430Retrograde filling - per root500$ - 0500$ - 0500$ - 0600$ - 0600$ - 0600$ - 0600$ - 0$ - 0
D3431Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery20$ - 020$ - 030$ - 030$ - 030$ - 030$ - 030$ - 0$ - 0
D3432Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D3450Root amputation - per root4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D3460Endodontic endosseous implant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3470Intentional reimplantation (including necessary splinting)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3910Surgical procedure for isolation of tooth with rubber dam80$ - 080$ - 080$ - 080$ - 080$ - 080$ - 080$ - 0$ - 0
D3920Hemisection (including any root removal), not including root canal therapy1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D3950Canal preparation and fitting of preformed dowel or post40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D3999Unspecified endodontic procedure, by report2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant80$ - 080$ - 080$ - 080$ - 080$ - 080$ - 080$ - 0$ - 0
D4212Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth70$ - 070$ - 070$ - 070$ - 070$ - 070$ - 070$ - 0$ - 0
D4230Anatomical crown exposure - four or more contiguous teeth or tooth bounded tooth spaces per quadrant6$ - 06$ - 06$ - 06$ - 06$ - 06$ - 06$ - 0$ - 0
D4231Anatomical crown exposure - one to three teeth or tooth bounded tooth spaces per quadrant10$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D4240Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant60$ - 060$ - 070$ - 070$ - 070$ - 070$ - 070$ - 0$ - 0
D4241Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D4245Apically positioned flap5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D4249Clinical crown lengthening - hard tissue700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0$ - 0
D4260Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant1,400$ - 01,400$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 0$ - 0
D4261Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant600$ - 0600$ - 0600$ - 0600$ - 0600$ - 0600$ - 0600$ - 0$ - 0
D4263Bone replacement graft -retained natural tooth- first site in quadrant900$ - 0900$ - 0900$ - 0900$ - 0900$ - 0900$ - 0900$ - 0$ - 0
D4264Bone replacement graft - retained natural tooth-each additional site in quadrant400$ - 0400$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D4265Biologic materials to aid in soft and osseous tissue regeneration900$ - 01,000$ - 01,000$ - 01,000$ - 01,000$ - 01,000$ - 01,000$ - 0$ - 0
D4266Guided tissue regeneration - resorbable barrier, per site1,400$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 01,500$ - 0$ - 0
D4267Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0$ - 0
D4268Surgical revision procedure, per tooth5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D4270Pedicle soft tissue graft procedure100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D4273Autogenous connective tissue graft procedure (including donor and recipient surgical sites)first tooth, implant or edentulous tooth position in graft700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0700$ - 0$ - 0
D4274Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D4275Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant or edentulous tooth position in graft200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D4276Combined connective tissue and double pedicle graft, per tooth100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D4277Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or dentulous tooth position in graft200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D4278Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or dentulous tooth position in same graft site90$ - 090$ - 090$ - 090$ - 090$ - 090$ - 090$ - 0$ - 0
D4283Autogenous connective tissue graft pocedure (including recipient surgical site and donor material) - each additional contguous tooth, implant or edentulous tooth position in same graft site300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0300$ - 0$ - 0
D4285Non-autogenous connective tissue graft pocedure (including recipient surgical site and donor material) - each additional contguous tooth, implant or edentulous tooth position in same graft site200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D4320Provisional splinting - intracoronal1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D4321Provisional splinting - extracoronal20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D4341Periodontal scaling and root planing - four or more teeth per quadrant10,400$ - 010,500$ - 010,600$ - 010,600$ - 010,600$ - 010,600$ - 010,600$ - 0$ - 0
D4342Periodontal scaling and root planing - one to three teeth per quadrant2,300$ - 02,300$ - 02,300$ - 02,300$ - 02,300$ - 02,300$ - 02,300$ - 0$ - 0
D4346Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D4355Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit800$ - 0800$ - 0800$ - 0800$ - 0800$ - 0800$ - 0800$ - 0$ - 0
D4381Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0500$ - 0$ - 0
D4910Periodontal maintenance9,500$ - 09,500$ - 09,500$ - 09,500$ - 09,500$ - 09,500$ - 09,500$ - 0$ - 0
D4920Unscheduled dressing change (by someone other than treating dentist or their staff)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D4921Gingival irrigation - per quadrant200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0
D4999Unspecified periodontal procedure, by report6$ - 06$ - 06$ - 06$ - 06$ - 06$ - 06$ - 0$ - 0
D5110Complete denture - maxillary30$ - 030$ - 030$ - 030$ - 030$ - 030$ - 030$ - 0$ - 0
D5120Complete denture - mandibular10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D5130Immediate denture - maxillary10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D5140Immediate denture - mandibular5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D5211Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D5212Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)3$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D5213Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D5214Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)40$ - 040$ - 040$ - 040$ - 040$ - 040$ - 040$ - 0$ - 0
D5221Immediate maxillary partial denture - resin base(including retentive/clasping materials, rests and teeth4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D5222Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth)2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D5223Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5224Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5225Maxillary partial denture - flexible base (including any clasps, rests and teeth)20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D5226Mandibular partial denture - flexible base (including any clasps, rests and teeth)20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D5282Removable unilateral partial denture - one piece cast metal (including clasps and teeth), maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5283Removable unilateral partial denture - one piece cast metal (including clasps and teeth), mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5284Removable unilateral partial denture - one piece flxible base (including clasps and teeth) - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5286Removable unilateral partial denture - one piece resin (including clasps and teeth) - per quadrant1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5410Adjust complete denture - maxillary2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D5411Adjust complete denture - mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5421Adjust partial denture - maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5422Adjust partial denture - mandibular3$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D5511Repair broken complete denture base, mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5512Repair broken complete denture base, maxillary4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D5520Replace missing or broken teeth - complete denture (each tooth)10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D5611Repair resin partial denture base, mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5612Repair resin partial denture base, maxillary5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D5621Repair cast partial framework, mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5622Repair cast partial framework, maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5630Repair or replace broken clasp retentive clasping materials - per tooth4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D5640Replace broken teeth - per tooth30$ - 030$ - 030$ - 030$ - 030$ - 030$ - 030$ - 0$ - 0
D5650Add tooth to existing partial denture7$ - 07$ - 07$ - 07$ - 07$ - 07$ - 07$ - 0$ - 0
D5660Add clasp to existing partial denture - per tooth2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D5670Replace all teeth and acrylic on cast metal framework (maxillary)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5671Replace all teeth and acrylic on cast metal framework (mandibular)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5710Rebase complete maxillary denture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5711Rebase complete mandibular denture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5720Rebase maxillary partial denture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5721Rebase mandibular partial denture1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5730Reline complete maxillary denture (chairside)5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D5731Reline complete mandibular denture (chairside)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5740Reline maxillary partial denture (chairside)2$ - 02$ - 02$ - 02$ - 02$ - 02$ - 02$ - 0$ - 0
D5741Reline mandibular partial denture (chairside)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5750Reline complete maxillary denture (laboratory)4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D5751Reline complete mandibular denture (laboratory)3$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D5760Reline maxillary partial denture (laboratory)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5761Reline mandibular partial denture (laboratory)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5810Interim complete denture (maxillary)2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D5811Interim complete denture (mandibular)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5820Interim partial denture (maxillary)100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0100$ - 0$ - 0
D5821Interim partial denture (mandibular)20$ - 020$ - 020$ - 020$ - 020$ - 020$ - 020$ - 0$ - 0
D5850Tissue conditioning, maxillary10$ - 010$ - 010$ - 010$ - 010$ - 010$ - 010$ - 0$ - 0
D5851Tissue conditioning, mandibular6$ - 06$ - 07$ - 07$ - 07$ - 07$ - 07$ - 0$ - 0
D5862Precision attachment, by report9$ - 09$ - 09$ - 09$ - 09$ - 09$ - 09$ - 0$ - 0
D5863overdenture - complete maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5864overdenture - partial maxillary1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5865overdenture - complete mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5866overdenture - partial mandibular1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5867Replacement of replaceable part of semi-precision or precision attachment ( male or female component)4$ - 04$ - 04$ - 04$ - 04$ - 04$ - 04$ - 0$ - 0
D5875Modification of removable prosthesis following implant surgery5$ - 05$ - 05$ - 05$ - 05$ - 05$ - 05$ - 0$ - 0
D5876add metal substructure to acrylic full denture (per arch)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5899Unspecified removable prosthodontic procedure, by report1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5911Facial moulage (sectional)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5912Facial moulage (complete)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5913Nasal prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5914Auricular prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5915Orbital prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5916Ocular prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5919Facial prosthesis2$ - 03$ - 03$ - 03$ - 03$ - 03$ - 03$ - 0$ - 0
D5922Nasal septal prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5923Ocular prosthesis, interim1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5924Cranial prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5925Facial augmentation implant prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5926Nasal prosthesis, replacement1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5927Auricular prosthesis, replacement1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5928Orbital prosthesis, replacement1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5929Facial prosthesis, replacement1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5931Oburator prosthesis, surgical1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5932Obturator prosthesis, definitive1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5933Obturator prosthesis, modification1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5934Mandibular resection prosthesis with guide flange1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5935Mandibular resection prosthesis without guide flange1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5936Obturator prosthesis, interim1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5937Trismus appliance (not for TMD treatment)1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5953Speech aid prosthesis, adult1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5954Palatal augmentation prosthesis1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5955Palatal lift prosthesis, definitive1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5958Palatal lift prosthesis, interim1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5959Palatal lift prosthesis, modification1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5960Speech aid prosthesis, modification1$ - 01$ - 01$ - 01$ - 01$ - 01$ - 01$ - 0$ - 0
D5982Surgical stent200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0200$ - 0$ - 0

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File details come from the government source that posted it. Updated .