Exhibit_A_CDT_Pricing_Table_National_Amend_1.xls

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Active Duty Dental Program (ADDP)
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HT9402-13-R-0002
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EXHIBIT A

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OP

Exhibit A
TRICARE ACTIVE DUTY DENTAL PROGRAM - HT9402-13-R-0002 - CDT PRICING TABLE
Option Period 1Option Period 2Option Period 3Option Period 4Option Period 5Estimated Total
Procedure CodeDescriptionEstimated Quantity For Each OPUnit PriceExtended PriceUnit PriceExtended PriceUnit PriceExtended PriceUnit PriceExtended PriceUnit PriceExtended Price
D0120Periodic oral evaluation - established patient54,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0140Limited oral evaluation - problem focused74,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0150Comprehensive oral evaluation - new or established patient32,250$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0160Detailed and extensive oral evaluation - problem focused, by report1,200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0170Re-evaluation - limited, problem focused (established patient, not post-operative visit)250$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0180Comprehensive periodontal evaluation - new or established patient3,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0190screening of a patient1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0191assessment of a patient1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0210Intraoral - complete series of radiographic images13,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0220Intraoral - periapical first radiographic image59,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0230Intraoral - periapical each additional radiographic image30,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0240Intraoral - occlusal radiographic image60$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0250Extraoral - first radiographic image40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0260Extraoral - each additional radiographic image40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0270Bitewing - single radiographic image3,100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0272Bitewings - two radiographic images9,400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0273Bitewings - three radiographic images150$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0274Bitewings - four radiographic images47,100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0277Vertical bitewings - 7 to 8 radiographic images325$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0290Posterior-anterior or lateral skull and facial bone survey radiographic image5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0310Sialography1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0320Temporomandibular joint arthrogram, including injection5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0321Other temporomandibular joint radiographic images, by report5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0322Tomographic survey80$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0330Panoramic radiographic image30,400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0340Cephalometric radiographic image200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0350Oral/facial photographic images400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0363Cone beam-three dimensional image reconstruction using existing data, includes multiple images750$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0364Cone beam CT capture and interpretation with limited field of view - less than one whole jaw25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0365Cone beam CT capture and interpretation with limited field of view of one full dental arch - mandible25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0366Cone beam CT capture and interpretation with limited field of view of one full dental arch - maxilla, with or without cranium25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0367Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium105$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0368Cone beam CT capture and interpretation for TMJ series including two or more exposures25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0369Maxillofacial MRI capture and interpretation50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0370Maxillofacial ultrasound capture and interpretation25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0371Sialoendoscopy capture and interpretation1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0380Cone beam CT image capture with limited field of view - less than one whole jaw5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0381Cone beam CT image capture with limited field of view of one full dental arch - mandible5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0382Cone beam CT imagae capture with limited field of view of one full dental arch - maxilla, with or without cranium5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0383Cone beam CT image capture with field of view of both jaws, with or without cranium100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0384Cone beam CT image capture for TMJ series including two or more exposures5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0385Maxillofacial MRI image capture1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0386Maxillofacial ultrasound image capture1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0391Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0415Collection of microorganisms for culture and sensitivity10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0416Viral culture1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0417Collection and preparation of saliva sample for laboratory diagnostic testing1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0418Analysis of saliva sample1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0421Genetic test for susceptiblility to oral diseases1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0425Caries susceptibility tests5$ - 0$ - 0$ - 0$ - 0$ - 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 procedures160$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0460Pulp vitality tests100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0470Diagnostic casts900$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0472Accession of tissue, gross examination preparation and transmission of written report1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0473Accession of tissue, gross and microscopic examination, preparation and transmission of written report30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0474Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report80$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0475Decalcification procedure3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0476Special stains for microorganisms1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0477Special stains, not for microorganisms2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0478Imminohistochemical stains1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0479Tissue in-situ hybridization, including interpretation1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0480Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0481Electron microscopy - diagnostic1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0482Direct immunofluorescence1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0483Indirect immunofluorescence1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0484Consultation on slides prepared elsewhere5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0485Consultation, including preparation of slides from biopsy material supplied by referring source5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0486Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0502Other oral pathology procedures, by report3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D0999Unspecified diagnostic procedure, by report60$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1110Prophylaxis - adult96,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1206Topical application of fluoride varnish4,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1208Topical application of fluoride33,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1310Nutritional counseling for control of dental disease1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1320Tobacco counseling for the control and prevention of oral disease1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1330Oral hygiene instructions15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1351Sealant - per tooth2,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1352Preventive resin restoration in a moderate to high caries risk patient - permanent tooth300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1510Space maintainer - fixed - unilateral3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1515Space maintainer - fixed - bilateral1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1520Space maintainer - removable - unilateral5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1525Space maintainer - removable - biilateral1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1550Re-cementation of space maintainer2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D1555Removal of fixed space maintainer2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2140Amalgam - one surface, primary or permanent17,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2150Amalgam - two surfaces, primary or permanent30,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2160Amalgam - three surfaces, primary or permanent10,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2161Amalgam - four or more surfaces, primary or permanent2,200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2330Resin-based composite - one surface, anterior8,600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2331Resin-based composite - two surfaces, anterior9,800$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2332Resin-based composite - three surfaces, anterior5,600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2335Resin-based composite - four or more surfaces or involving incisal angle (anterior)3,700$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2390Resin-based composite crown, anterior10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2391Resin-based composite - one surface, posterior26,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2392Resin-based composite - two surfaces, posterior26,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2393Resin-based composite - three surfaces, posterior10,700$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2394Resin-based composite - four or more surfaces, posterior2,600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2410Gold foil - one surface1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2420Gold foil - two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2430Gold foil - three surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2510Inlay - metallic - one surface1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2520Inlay - metallic - two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2530Inlay - metallic - three or more surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2542Onlay - metallic - two surfaces2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2543Onlay - metallic - three surfaces20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2544Onlay - metallic - four or more surfaces20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2610Inlay - porcelain/ceramic - one surface1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2620Inlay - porcelain/ceramic - two surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2630Inlay - porcelain/ceramic - three or more surfaces10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2642Onlay - porcelain/ceramic - two surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2643Onlay - porcelain/ceramic - three surfaces40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2644Onlay - porcelain/ceramic - four or more surfaces60$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2650Inlay - resin-based composite - one surface1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2651Inlay - resin-based composite - two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2652Inlay - resin-based composite - three or more surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2662Onlay - resin-based composite - two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2663Onlay - resin-based composite - three surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2664Onlay - resin-based composite - four or more surfaces10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2710Crown - resin - based composite (indirect)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2712Crown - 3/4 resin-based composite (indirect)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2720Crown - resin with high noble metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2721Crown - resin with predominantly base metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2722Crown - resin with noble metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2740Crown - porcelain/ceramic substrate6,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2750Crown - porcelain fused to high noble metal28,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2751Crown - porcelain fused to predominantly base metal300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2752Crown - porcelain fused to noble metal2,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2780Crown - 3/4 cast high noble metal20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2781Crown - 3/4 cast predominantly base metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2782Crown - 3/4 cast noble metal3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2783Crown - 3/4 porcelain/ceramic40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2790Crown - full cast high noble metal11,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2791Crown - full cast predominantly base metal10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2792Crown - full cast noble metal950$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2794Crown - titanium1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2799Provisional crown - further treatment or completion of diagnosis necessary prior to final impression275$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2910Recement inlay, onlay, or partial coverage restoration25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2915Recement cast or prefabricated post and core5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2920Recement crown600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2931Prefabricated stainless steel crown - permanent tooth25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2932Prefabricated resin crown5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2933Prefabricated stainless steel crown with resin window1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2940Protective restoration500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2950Core buildup, including any pins14,400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2951Pin retention - per tooth, in addition to restoration100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2952Post and core in addition to crown, indirectly fabricated700$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2953Each additional indirectly fabricated post - same tooth1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2954Prefabricated post and core in addition to crown3,300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2955Post removal (not in conjunction with endodontic therapy)50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2957Each additional prefabricated post - same tooth5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2960Labial veneer (resin laminate) - chairside10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2961Labial veneer (resin laminate) - laboratory5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2962Labial veneer (porcelain laminate) - laboratory500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2970Temporary crown (fractured tooth)100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2971Additional procedures to construct new crown under existing partial denture framework20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2975Coping1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2980Crown repair, necessitated by restorative material failure105$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2981Inlay repair necessitated by restorative material failure1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2982Onlay repair necessitated by restorative material failure1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2983Veneer repair necessitated by restorative material failure1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2990Resin infiltration of incipient smooth surface lesions1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D2999Unspecified restorative procedure, by report30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3110Pulp cap - direct (excluding final restoration)125$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3120Pulp cap - indirect (excluding final restoration)75$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3220Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament130$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3221Pulpal debridement, primary and permanent teeth350$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3310Endodontic therapy - anterior (excluding final restoration)2,400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3320Endodontic therapy - bicuspid (excluding final restoration)3,100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3330Endodontic therapy - molar (excluding final restoration)10,100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3331Treatment of root canal obstruction, non-surgical access200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3332Incomplete endodontic therapy, inoperable, unrestorable or fractured tooth150$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3333Internal root repair of perforation defects50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3346Retreatment of previous root canal therapy - anterior500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3347Retreatment of previous root canal therapy - bicuspid300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3348Retreatment of previous root canal therapy - molar1,800$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3351Apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3352Apexification/recalcificationpulpal regeneration - interim medication replacement10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3353Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3354Pulpal regeneration - (completion of regenerative treatment in an immature permanent tooth with a necrotic pulp); does not include final restoration5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3410Apicoectomy/periradicular surgery - anterior200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3421Apicoectomy/periradicular surgery - bicuspid (first root)50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3425Apicoectomy/periradicular surgery - molar (first root)200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3426Apicoectomy/periradicular surgery (each additional root)100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3430Retrograde filling - per root400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3450Root amputation - per root10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3460Endodontic endosseous implant1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3470Intentional reimplantation (including necessary splinting)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3910Surgical procedure for isolation of tooth with rubber dam5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3920Hemisection (including any root removal), not including root canal therapy2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3950Canal preparation and fitting of preformed dowel or post50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D3999Unspecified endodontic procedure, by report5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4212Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4230Anatomical crown exposure - four or more contiguous teeth per quadrant10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4231Anatomical crown exposure - one to three teeth per quadrant10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4240Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4241Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant130$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4245Apically positioned flap10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4249Clinical crown lengthening - hard tissue1,600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4260Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant1,900$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4261Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant1,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4263Bone replacement graft - first site in quadrant1,600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4264Bone replacement graft - each additional site in quadrant300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4265Biologic materials to aid in soft and osseous tissue regeneration700$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4266Guided tissue regeneration - resorbable barrier, per site800$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4267Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)120$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4268Surgical revision procedure, per tooth30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4270Pedicle soft tissue graft procedure100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4273Subepithelial connective tissue graft procedures, per tooth1,100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4274Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4275Soft tissue allograft300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4276Combined connective tissue and double pedicle graft, per tooth10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4277Free soft tissue graft procedure (including donor site surgery), first tooth or dentulous tooth position in a graft20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4278Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or dentulous tooth position in same graft site5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4320Provisional splinting - intracoronal5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4321Provisional splinting - extracoronal30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4341Periodontal scaling and root planing - four or more teeth per quadrant20,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4342Periodontal scaling and root planing - one to three teeth per quadrant2,600$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4355Full mouth debridement to enable comprehensive evaluation and diagnosis2,400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4381Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth150$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4910Periodontal maintenance9,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4920Unscheduled dressing change (by someone other than treating dentist)2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D4999Unspecified periodontal procedure, by report20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5110Complete denture - maxillary130$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5120Complete denture - mandibular50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5130Immediate denture - maxillary50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5140Immediate denture - mandibular20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5211Maxillary partial denture - resin base (including any conventional clasps, rests and teeth)70$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5212Mandibular partial denture - resin base (including any conventional clasps, rests and teeth25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5213Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)380$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5214Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5225Maxillary partial denture - flexible base (including any clasps, rests and teeth)70$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5226Mandibular partial denture - flexible base (including any clasps, rests and teeth)70$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5281Removable unilateral partial denture - one piece cast metal (including clasps and teeth)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5410Adjust complete denture - maxillary5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5411Adjust complete denture - mandibular5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5421Adjust partial denture - maxillary10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5422Adjust partial denture - mandibular10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5510Repair broken complete denture base15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5520Replace missing or broken teeth - complete denture (each tooth)30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5610Repair resin denture base30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5620Repair cast framework5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5630Repair or replace broken clasp15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5640Replace broken teeth - per tooth30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5650Add tooth to existing partial denture35$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5660Add clasp to existing partial denture5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5670Replace all teeth and acrylic on cast metal framework (maxillary)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5671Replace all teeth and acrylic on cast metal framework (mandibular)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5710Rebase complete maxillary denture5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5711Rebase complete mandibular denture5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5720Rebase maxillary partial denture2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5721Rebase mandibular partial denture2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5730Reline complete maxillary denture (chairside)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5731Reline complete mandibular denture (chairside)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5740Reline maxillary partial denture (chairside)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5741Reline mandibular partial denture (chairside)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5750Reline complete maxillary denture (laboratory)40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5751Reline complete mandibular denture (laboratory)15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5760Reline maxillary partial denture (laboratory)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5761Reline mandibular partial denture (laboratory)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5810Interim complete denture (maxillary)15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5811Interim complete denture (mandibular)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5820Interim partial denture (maxillary)220$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5821Interim partial denture (mandibular)40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5850Tissue conditioning, maxillary45$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5851Tissue conditioning, mandibular15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5860Overdenture - complete, by report15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5861Overdenture - partial, by report5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5862Precision attachment, by report65$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5867Replacement of replaceable part of semi-precision or precision attachment ( male or female component)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5875Modification of removable prosthesis following implant surgery3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5899Unspecified removable prosthodontic procedure, by report5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5911Facial moulage (sectional)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5912Facial moulage (complete)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5913Nasal prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5914Auricular prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5915Orbital prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5916Ocular prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5919Facial prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5922Nasal septal prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5923Ocular prosthesis, interim1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5924Cranial prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5925Facial augmentation implant prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5926Nasal prosthesis, replacement1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5927Auricular prosthesis, replacement1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5928Orbital prosthesis, replacement1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5929Facial prosthesis, replacement1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5931Oburator prosthesis, surgical1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5932Obturator prosthesis, definitive1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5933Obturator prosthesis, modification1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5934Mandibular resection prosthesis with guide flange1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5935Mandibular resection prosthesis without guide flange1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5936Obturator prosthesis, interim1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5937Trismus appliance (not for TMD treatment)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5953Speech aid prosthesis, adult1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5954Palatal augmentation prosthesis1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5955Palatal lift prosthesis, definitive1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5958Palatal lift prosthesis, interim1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5959Palatal lift prosthesis, modification1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5960Speech aid prosthesis, modification1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5982Surgical stent350$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5983Radiation carrier1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5984Radiation shield1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5985Radiation cone locator1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5986Fluoride gel carrier10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5987Commissure splint1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5988Surgical splint15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5991Topical medicament carrier1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5992Adjust maxillofacial prosthetic appliance, by report1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5993Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D5999Unspecified maxillofacial prosthesis, by report5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6010Surgical placement of implant body: endosteal implant2,300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6012Surgical placement of interim implant body for transitional prosthesis; endosteal implant2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6040Surgical placement: eposteal implant5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6050Surgical placement: transosteal implant1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6051Interim abutment1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6053Implant/abutment supported removable denture for completely edentulous arch15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6054Implant/abutment supported removable denture for partially edentulous arch5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6055Connecting bar - implant supported or abutment supported10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6056Prefabricated abutment - includes modification and placement700$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6057Custom fabricated abutment - includes placement1,400$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6058Abutment supported porcelain/ceramic crown300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6059Abutment supported porcelain fused to metal crown (high noble metal)1,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6060Abutment supported porcelain fused to metal crown ( predominantly base metal)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6061Abutment supported porcelain fused to metal crown (noble metal)100$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6062Abutment supported cast metal crown (high noble metal)70$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6063Abutment supported cast metal crown (predominantly base metal)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6064Abutment supported cast metal crown (noble metal)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6065Implant supported porcelain/ceramic crown115$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6066Implant supported porcelain fused to metal crown (titanium alloy, high noble metal)275$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6067Implant supported metal crown30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6068Abutment supported retainer for porcelain/ceramic FPD25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6069Abutment supported retainer for porcelain fused to metal FPD (high noble metal)80$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6070Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6071Abutment supported retainer for porcelain fused to metal FPD (noble metal)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6072Abutment supported retainer for porcelain fused to metal FPD (high noble metal)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6073Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6074Abutment supported retainer for cast metal FPD (noble metal)2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6075Implant supported retainer for ceramic FPD5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6076Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6077Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6078Implant/abutment supported fixed denture for completely edentulous arch10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6079Implant/abutment supported fixed denture for partially edentulous arch2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6080Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis80$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6090Repair implant supported prosthesis, by report5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6091Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6092Recement implant/abutment supported crown10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6093Recement implant/abutment supported fixed partial denture1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6094Abutment supported crown - (titanium)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6095Repair implant abutment, by report10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6100Implant removal, by report45$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6101Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6102Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6103Bone graft for repair or periimplant defect - not including flap entry and closure or, when indicated placement of a barrier membrane or biologic materials to aid in osseous regeneration1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6104Bone graft at the time of implant placement1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6190Radiographic/surgical implant index, by report130$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6194Abutment supported retainer crown for FPD - (titanium)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6199Unspecified implant procedure, by report60$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6205Pontic - indirect resin based composite1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6210Pontic - cast high noble metal300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6211Pontic - cast predominantly base metal5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6212Pontic - cast noble metal30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6214Pontic - titanium5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6240Pontic - porcelain fused to high noble metal3,300$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6241Pontic - porcelain fused to predominantly base metal45$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6242Pontic - porcelain fused to noble metal370$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6245Pontic - porcelain/ceramic310$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6250Pontic - resin with high noble metal10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6251Pontic - resin with predominantly base metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6252Pontic - resin with noble metal3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6253Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6545Retainer - cast metal for resin bonded fixed prosthesis130$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6548Retainer - porcelain/ceramic for resin bonded fixed prosthesis35$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6600Inlay - porcelain/ceramic, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6601Inlay - porcelain/ceramic, three or more surfaces2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6602Inlay - cast high noble metal, two surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6603Inlay - cast high noble metal, three or more surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6604Inlay - cast predominantly base metal, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6605Inlay - cast predominantly base metal, three or more surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6606Inlay - cast noble metal, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6607Cast noble metal, three or more surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6608Onlay - porcelain/ceramic, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6609Onlay - porcelain/ceramic, three or more surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6610Onlay - cast high noble metal, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6611Onlay - cast high noble metal, three or more surfaces5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6612Onlay - cast predominantly base metal, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6613Onlay - cast predominantly base metal, three or more surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6614Onlay - cast noble metal, two surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6615Onlay - cast noble metal, three or more surfaces1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6624Inlay - titanium1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6634Onlay - titanium1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6710Crown - indirect resin based composite1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6720Crown - resin with high noble metal5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6721Crown - resin with predominantly base metal5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6722Crown - resin with noble metal2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6740Crown - porcelain/ceramic520$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6750Crown - porcelain fused to high noble metal5,500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6751Crown - porcelain fused to predominantly base metal60$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6752Crown - porcelain fused to noble metal500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6780Crown - 3/4 cast high noble metal20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6781Crown - 3/4 cast predominantly base metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6782Crown - 3/4 cast noble metal1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6783Crown - 3/4 porcelain/ceramic3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6790Crown - full cast high noble metal650$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6791Crown - full cast predominantly base metal2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6792Crown - full cast noble metal65$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6793Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression90$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6794Crown - titanium1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6920Connector Bar1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6930Recement fixed partial denture75$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6940Stress breaker15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6950Precision attachment50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6975Coping5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6980Fixed partial denture repair, necessitated by restorative material failure10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D6999Unspecified fixed prosthodontic procedure, by report10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7111Extraction, coronal remnants - deciduous tooth30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7140Extraction, erupted tooth or exposed root (elevation and/or forceps removal)8,200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7210Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated23,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7220Removal of impacted tooth - soft tissue6,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7230Removal of impacted tooth - partially bony23,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7240Removal of impacted tooth - completely bony24,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7241Removal of impacted tooth - completely bony, with unusual surgical complications2,000$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7250Surgical removal of residual tooth roots (cutting procedure)500$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7251Coronectomy20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7260Oroantral fistula closure20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7261Primary closure of a sinus perforation35$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7270Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7272Tooth transplantation (includes reimplantation from one site to another and splinting and / or stabilization)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7280Surgical access of an unerupted tooth30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7282Mobilization of erupted or malpositioned tooth to aid eruption2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7283Placement of device to facilitate eruption of impacted tooth20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7285Biopsy of oral tissue - hard (bone, tooth)70$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7286Biopsy of oral tissue - soft450$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7287Exfoliative cytological sample collection1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7288Brush biopsy - transepithelial sample collection5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7290Surgical repositioning of teeth2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7291Transseptal fiberotomy/supra crestal fiberotomy, by report15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7292Surgical placement: temporary anchorage device [screw retained plate] requiring surgical flap1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7293Surgical placement: temporary anchorage device requiring surgical flap2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7294Surgical placement: temporary anchorage device without surgical flap5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7295Harvest of bone for use in autogenous grafting procedure2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7310Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces per quadrant80$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7311Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces per quadrant20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7320Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces per quadrant20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7321Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces per quadrant10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7340Vestibuloplasty - ridge extension (secondary epithelialization)2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7350Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7410Excision of benign lesion up to 1.25 cm150$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7411Excision of benign lesion greater than 1.25 cm40$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7412Excision of benign lesion, complicated15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7413Excision of malignant lesion up to 1.25 cm1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7414Excision of malignant lesion greater than 1.25 cm1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7415Excision of malignant lesion, complicated1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7440Excision of malignant tumor - lesion diameter up to 1.25 cm3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7441Excision of malignant tumor - lesion diameter greater than 1.25 cm3$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7450Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7451Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7460Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm25$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7461Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7465Destruction of lesion(s) by physical or chemical method, by report15$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7471Removal of lateral exostosis (maxilla or mandible)45$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7472Removal of torus palatinus5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7473Removal of torus mandibularis50$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7485Surgical reduction of osseous tuberosity5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7490Radical resection of maxilla or mandible2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7510Incision and drainage of abscess - intraoral soft tissue200$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7511Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7520Incision and drainage of abscess - extraoral soft tissue5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7521Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces)5$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7530Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7540Removal of reaction producing foreign bodies, musculoskeletal system20$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7550Partial ostectomy/sequestrectomy for removal of non-vital bone30$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7560Maxillary sinusotomy for removal of tooth fragment or foreign body10$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7610Maxilla - open reduction (teeth immobilized, if present)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7620Maxilla - closed reduction (teeth immobilized, if present)1$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0
D7630Mandible - open reduction (teeth immobilized, if present)2$ - 0$ - 0$ - 0$ - 0$ - 0$ - 0

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