Exhibit_A_CDT_Pricing_Table_National.xls

XLS spreadsheet 214 KB Posted Mar 3, 2013

Attached to: Active Duty Dental Program (ADDP)
Solicitation number: HT9402-13-R-0002
Issued by: Defense Health Agency

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Exhibit A CDT Pricing

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File	Type	Posted
Q A_Set__6_ADDP_Solicitation.docx	DOCX document	Apr 4, 2013
Sections_C-M_Amend_2_27Mar2013_FINAL.pdf	PDF	Apr 2, 2013
SF30_Amend_0002.pdf	PDF	Apr 2, 2013
Q A_Set_5_.docx	DOCX document	Apr 1, 2013
Q A_Set__4.docx	DOCX document	Mar 26, 2013
FINAL_Sections_C-M_Amend_1_22Mar2013.rtf	RTF text file	Mar 22, 2013
Attach_J-16_Transition_Amend_1.doc	DOC document	Mar 22, 2013
Exhibit_A_CDT_Pricing_Table_National_Amend_1.xls	XLS spreadsheet	Mar 22, 2013
Amendment_0001.pdf	PDF	Mar 22, 2013
Attach_J-2_Benefits_Amend_1.doc	DOC document	Mar 22, 2013
Q A_Set_3_ADDP_Solicitation.docx	DOCX document	Mar 21, 2013
QA_Set_2_ADDP_Solicitation_HT9402-13-R-0002.docx	DOCX document	Mar 19, 2013
Q A_Set_1 _ADDP_Solicitation_HT9402-13-R-0002.docx	DOCX document	Mar 11, 2013
Exibit_B_CDRL_Table_of_Contents.doc	DOC document	Mar 3, 2013
HT9402-13-R-0002 _ADDP.zip	ZIP file	Mar 3, 2013
Section_J_Attachments.zip	ZIP file	Mar 3, 2013

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OP 1

	Attachment J-22
TRICARE ACTIVE DUTY DENTAL PROGRAM - HT9402-13-R-0002 - CDT PRICING SHEET
	OPTION PERIOD 1		Option Period 1		Option Period 2		Option Period 3		Option Period 4		Option Period 5		Estimated Total
Procedure Code	Description	Estimated Quantity	Unit Price	Extended Price	Unit Price	Extended Price	Unit Price	Extended Price	Unit Price	Extended Price	Unit Price	Extended Price
D0120	Periodic oral evaluation - established patient	54,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0140	Limited oral evaluation - problem focused	74,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0150	Comprehensive oral evaluation - new or established patient	32,250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0160	Detailed and extensive oral evaluation - problem focused, by report	1,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0170	Re-evaluation - limited, problem focused	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0180	Comprehensive periodontal evaluation - new or established patient	3,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0210	Intraoral - complete series (including bitewings)	13,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0220	Intraoral - periapical first film	59,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0230	Intraoral - periapical each additional film	34,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0240	Intraoral - occlusal film	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0250	Extraoral - first film	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0260	Extraoral - each additional film	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0270	Bitewing - single film	3,100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0272	Bitewings - two films	9,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0273	Bitewings - three films	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0274	Bitewings - four films	47,100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0277	Vertical bitewings - 7 to 8 films	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0310	Sialography	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0320	Temporomandibular joint arthrogram, including injection	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0321	Other temporomandibular joint films, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0322	Tomographic survey	80		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0330	Panoramic film	30,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0340	Cephalometric film	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0350	Oral/facial photographic images	400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0364	Cone beam CT capture and interpretation with limited field of view - less than one whole jaw	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0365	Cone beam CT capture and interpretation with limited field of view of one full dental arch - mandible	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0366	Cone beam CT capture and interpretation with limited field of view of one full dental arch - maxilla, with or without cranium	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0367	Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0368	Cone beam CT capture and interpretation for TMJ series including two or more exposures	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0369	Maxillofacial MRI capture and interpretation	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0370	Maxillofacial ultrasound capture and interpretation	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0371	Sialoendoscopy capture and interpretation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0380	Cone beam CT capture with limited field of view - less than one whole jaw	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0381	Cone beam CT capture with limited field of view of one full dental arch - mandible	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0382	Cone beam CT capture with limited field of view of one full dental arch - maxilla, with or without cranium	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0383	Cone beam CT capture with field of view of both jaws, with or without cranium	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0384	Cone beam CT capture for TMJ series including two or more exposures	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0385	Maxillofacial MRI image capture	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0386	Maxillofacial ultrasound image capture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0391	interpretation of diagnostic image by a practitioner not associated with capture of the image, including report	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0415	Collection of microorganisms for culture and sensitivity	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0416	Viral culture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0425	Caries susceptibility tests	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0431	Adjunctive pre-diagnostic test	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0460	Pulp vitality tests	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0470	Diagnostic casts	900		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0472	Accession of tissue, gross examination preparation and transmission of written report	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0473	Accession of tissue, gross and microscopic examination, preparation and transmission of written report	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0474	Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report	80		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0475	Decalcification procedure	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0477	Special stains for microorganisms	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0477	Special stains, not for microorganisms	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0478	Imminohistochemical stains	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0479	Tissue in-situ hybridization, including interpretation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0480	Accession of exfoliative cytologic smears	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0481	Electron microscopy - diagnostic	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0482	Direct immunofluorescence	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0483	Indirect immunofluorescence	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0484	Consultation on slides prepared elsewhere	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0485	Consultation, including preparation of slides from biopsy material supplied by referring source	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0502	Other oral pathology procedures, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0999	Unspecified diagnostic procedure, by report	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1110	Prophylaxis - adult	96,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1206	Topical application of fluoride varnish	5,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1208	Topical application of fluoride	33,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1330	Oral hygiene instructions	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1351	Sealant - per tooth	2,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1352	Preventive resin restoration in a moderate to high caries risk patient	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1555	Removal of fixed space maintainer	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2140	Amalgam - one surface, primary or permanent	17,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2150	Amalgam - two surfaces, primary or permanent	30,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2160	Amalgam - three surfaces, primary or permanent	10,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2161	Amalgam - four or more surfaces, primary or permanent	2,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2330	Resin-based composite - one surface, anterior	8,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2331	Resin-based composite - two surfaces, anterior	9,800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2332	Resin-based composite - three surfaces, anterior	5,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2335	Resin-based composite - four or more surfaces or involving incisal angle	3,700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2390	Resin-based composite crown, anterior	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2391	Resin-based composite - one surface, posterior	26,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2392	Resin-based composite - two surfaces, posterior	26,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2393	Resin-based composite - three surfaces, posterior	10,700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2394	Resin-based composite - four or more surfaces, posterior	2,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2530	Inlay - metallic - three or more surfaces	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2542	Onlay - metallic - two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2543	Onlay - metallic - three surfaces	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2544	Onlay - metallic - four or more surfaces	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2610	Inlay - porcelain/ceramic - one surface	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2620	Inlay - porcelain/ceramic - two surfaces	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2630	Inlay - porcelain/ceramic - three or more surfaces	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2642	Onlay - porcelain/ceramic - two surfaces	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2643	Onlay - porcelain/ceramic - three surfaces	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2644	Onlay - porcelain/ceramic - four or more surfaces	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2650	Inlay - resin-based composite - one surface	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2651	Inlay - resin-based composite - two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2652	Inlay - resin-based composite - three or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2662	Onlay - resin-based composite - two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2663	Onlay - resin-based composite - three surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2664	Onlay - resin-based composite - four or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2740	Crown - porcelain/ceramic substrate	6,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2750	Crown - porcelain fused to high noble metal	27,700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2751	Crown - porcelain fused to predominantly base metal	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2752	Crown - porcelain fused to noble metal	2,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2780	Crown - 3/4 cast high noble metal	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2781	Crown - 3/4 cast predominantly base metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2782	Crown - 3/4 cast noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2783	Crown - 3/4 porcelain/ceramic	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2790	Crown - full cast high noble metal	11,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2791	Crown - full cast predominantly base metal	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2792	Crown - full cast noble metal	950		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2794	Crown - titanium	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2799	Provisional crown	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2910	Recement inlay, onlay, or partial coverage restoration	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2915	Recement cast or prefabricated post and core	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2920	Recement crown	600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2931	Prefabricated stainless steel crown - permanent tooth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2932	Prefabricated resin crown	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2940	Protective restoration	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2950	Core buildup, including any pins	14,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2951	Pin retention - per tooth, in addition to restoration	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2952	Post and core in addition to crown, indirectly fabricated	650		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2954	Prefabricated post and core in addition to crown	3,300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2955	Post removal (not in conjunction with endodontic therapy)	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2957	Each additional prefabricated post - same tooth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2960	Labial veneer (resin laminate) - chairside	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2961	Labial veneer (resin laminate) - laboratory	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2962	Labial veneer (porcelain laminate) - laboratory	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2970	Temporary crown (fractured tooth)	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2971	Additional procedures to construct new crown under existing partial denture framework	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2975	Coping	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2980	Crown repair, by report	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2990	resin infiltration of incipient smooth surface lesions	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2999	Unspecified restorative procedure, by report	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3110	Pulp cap - direct (excluding final restoration)	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3120	Pulp cap - indirect (excluding final restoration)	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3220	Therapeutic pulpotomy (excluding final restoration)	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3221	Pulpal debridement, primary and permanent teeth	320		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3240	Pulpal therapy - posterior, primary tooth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3310	Anterior (excluding final restoration)	2,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3320	Bicuspid (excluding final restoration)	3,100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3330	Molar (excluding final restoration)	10,100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3331	Treatment of root canal obstruction, non-surgical access	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3332	Incomplete endodontic therapy, inoperable, unrestorable or fractured tooth	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3333	Internal root repair of perforation defects	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3346	Retreatment of previous root canal therapy - anterior	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3347	Retreatment of previous root canal therapy - bicuspid	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3348	Retreatment of previous root canal therapy - molar	1,800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3351	Apexification/recalcification - initial visit	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3352	Apexification/recalcification - interim medication replacement	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3353	Apexification/recalcification - final visit	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3354	Pulpal regeneration	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3410	Apicoectomy/periradicular surgery - anterior	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3421	Apicoectomy/periradicular surgery - bicuspid (first root)	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3425	Apicoectomy/periradicular surgery - molar (first root)	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3426	Apicoectomy/periradicular surgery (each additional root)	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3430	Retrograde filling - per root	400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3450	Root amputation - per root	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3460	Endodontic endosseous implant	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3470	Intentional reimplantation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3910	Surgical procedure for isolation of tooth with rubber dam	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3920	Hemisection	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3950	Canal preparation and fitting of preformed dowel or post	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3999	Unspecified endodontic procedure, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4210	Gingivectomy or gingivoplasty - four or more contiguous teeth	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4212	Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4230	Anatomical crown exposure - four or more contiguous teeth per quadrant	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4231	Anatomical crown exposure - one to three teeth per quadrant	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4240	Gingival flap procedure - four or more contiguous teeth	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4241	Gingival flap procedure - one to three contiguous teeth	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4245	Apically positioned flap	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4249	Clinical crown lengthening - hard tissue	1,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4260	Osseous surgery - four or more contiguous teeth	1,900		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4261	Osseous surgery - one to three contiguous teeth	1,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4263	Bone replacement graft - first site in quadrant	1,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4264	Bone replacement graft - each additional site in quadrant	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4265	Biologic materials to aid in soft and osseous tissue regeneration	800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4266	Guided tissue regeneration - resorbable barrier, per site	800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4267	Guided tissue regeneration - nonresorbable barrier, per site	120		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4268	Surgical revision procedure, per tooth	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4270	Pedicle soft tissue graft procedure	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4273	Subepithelial connective tissue graft procedures, per tooth	1,100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4274	Distal or proximal wedge procedure	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4275	Soft tissue allograft	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4276	Combined connective tissue and double pedicle graft, per tooth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4277	free soft tissue graft procedure, first tooth or dentulous tooth position in a graft	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4278	free soft tissue graft procedure, each additional contiguous tooth or dentulous tooth position in same graft site	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4320	Provisional splinting - intracoronal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4321	Provisional splinting - extracoronal	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4341	Periodontal scaling and root planing - four or more teeth per quadrant	19,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4342	Periodontal scaling and root planing - one to three teeth per quadrant	2,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4355	Full mouth debridement to enable comprehensive evaluation and diagnosis	2,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4381	Localized delivery of antimicrobial agents	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4910	Periodontal maintenance	8,800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4920	Unscheduled dressing change (by someone other than treating dentist)	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4999	Unspecified periodontal procedure, by report	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5110	Complete denture - maxillary	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5120	Complete denture - mandibular	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5130	Immediate denture - maxillary	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5140	Immediate denture - mandibular	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5211	Maxillary partial denture - resin base	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5212	Mandibular partial denture - resin base	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5213	Maxillary partial denture	380		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5214	Mandibular partial denture	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5225	Maxillary partial denture - flexible base	70		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5226	Mandibular partial denture - flexible base	70		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5281	Removable unilateral partial denture - one piece cast metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5410	Adjust complete denture - maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5411	Adjust complete denture - mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5421	Adjust partial denture - maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5422	Adjust partial denture - mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5510	Repair broken complete denture base	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5520	Replace missing or broken teeth - complete denture (each tooth)	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5610	Repair resin denture base	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5620	Repair cast framework	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5630	Repair or replace broken clasp	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5640	Replace broken teeth - per tooth	35		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5650	Add tooth to existing partial denture	35		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5660	Add clasp to existing partial denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5670	Replace all teeth and acrylic on cast metal framework (maxillary)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5671	Replace all teeth and acrylic on cast metal framework (mandibular)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5710	Rebase complete maxillary denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5711	Rebase complete mandibular denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5720	Rebase maxillary partial denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5721	Rebase mandibular partial denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5730	Reline complete maxillary denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5731	Reline complete mandibular denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5740	Reline maxillary partial denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5741	Reline mandibular partial denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5750	Reline complete maxillary denture (laboratory)	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5751	Reline complete mandibular denture (laboratory)	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5760	Reline maxillary partial denture (laboratory)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5761	Reline mandibular partial denture (laboratory)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5810	Interim complete denture (maxillary)	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5811	Interim complete denture (mandibular)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5820	Interim partial denture (maxillary)	220		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5821	Interim partial denture (mandibular)	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5850	Tissue conditioning, maxillary	45		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5851	Tissue conditioning, mandibular	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5860	Overdenture - complete, by report	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5861	Overdenture - partial, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5862	Precision attachment, by report	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5867	Replacement of replaceable part of semi-precision or precision attachment	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5875	Modification of removable prosthesis following implant surgery	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5899	Unspecified removable prosthodontic procedure, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5982	Surgical stent	340		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5986	Fluoride gel carrier	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5988	Surgical splint	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5999	Unspecified maxillofacial prosthesis, by report (For pricing, includes D5911 to D5960; D5983, D5984, D5985, D5987, D5992 and D5993)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6010	Surgical placement of implant body: endosteal implant	2,300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6012	Surgical placement of interim implant body for transitional prosthesis	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6040	Surgical placement: eposteal implant	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6050	Surgical placement: transosteal implant	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6051	Interim abutment	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6053	Implant/abutment supported removable denture for completely edentulous arch	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6054	Implant/abutment supported removable denture for partially edentulous arch	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6055	Dental implant supported connecting bar	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6056	Prefabricated abutment - includes placement	700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6057	Custom abutment - includes placement	1,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6058	Abutment supported porcelain/ceramic crown	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6059	Abutment supported porcelain fused to metal crown (high noble metal)	1,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6060	Abutment supported porcelain fused to metal crown	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6061	Abutment supported porcelain fused to metal crown (noble metal)	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6062	Abutment supported cast metal crown (high noble metal)	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6063	Abutment supported cast metal crown (predominantly base metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6064	Abutment supported cast metal crown (noble metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6065	Implant supported porcelain/ceramic crown	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6066	Implant supported porcelain fused to metal crown	275		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6067	Implant supported metal crown	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6068	Abutment supported retainer for porcelain/ceramic FPD	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6069	Abutment supported retainer for porcelain fused to metal FPD	80		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6070	Abutment supported retainer for porcelain fused to metal FPD	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6071	Abutment supported retainer for porcelain fused to metal FPD (noble metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6072	Abutment supported retainer for porcelain fused to metal FPD (high noble metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6073	Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6074	Abutment supported retainer for cast metal FPD (noble metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6075	Implant supported retainer for ceramic FPD	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6076	Implant supported retainer for porcelain fused to metal FPD	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6077	Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6078	Implant/abutment supported fixed denture for completely edentulous arch	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6079	Implant/abutment supported fixed denture for partially edentulous arch	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6080	Implant maintenance procedures	80		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6090	Repair implant supported prosthesis, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6091	Replacement of semi-precision or precision attachment	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6092	Recement implant/abutment supported crown	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6093	Recement implant/abutment supported fixed partial denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6094	Abutment supported crown - (titanium)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6095	Repair implant abutment, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6100	Implant removal, by report	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6101	Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6102	Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6103	Bone 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 regeneration	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6104	Bone graft at the time of implant placement	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6190	Radiographic/surgical implant index, by report	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6194	Abutment supported retainer crown for FPD - (titanium)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6199	Unspecified implant procedure, by report	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6210	Pontic - cast high noble metal	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6211	Pontic - cast predominantly base metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6212	Pontic - cast noble metal	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6214	Pontic - titanium	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6240	Pontic - porcelain fused to high noble metal	3,300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6241	Pontic - porcelain fused to predominantly base metal	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6242	Pontic - porcelain fused to noble metal	360		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6245	Pontic - porcelain/ceramic	310		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6250	Pontic - resin with high noble metal	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6251	Pontic - resin with predominantly base metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6252	Pontic - resin with noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6253	Provisional pontic	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6545	Retainer - cast metal for resin bonded fixed prosthesis	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6548	Retainer - porcelain/ceramic for resin bonded fixed prosthesis	35		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6600	Inlay - porcelain/ceramic, two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6601	Inlay - porcelain/ceramic, three or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6602	Inlay - cast high noble metal, two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6603	Inlay - cast high noble metal, three or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6608	Onlay - porcelain/ceramic, two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6609	Onlay - porcelain/ceramic, three or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6611	Onlay - cast high noble metal, three or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6720	Crown - resin with high noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6721	Crown - resin with predominantly base metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6722	Crown - resin with noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6740	Crown - porcelain/ceramic	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6750	Crown - porcelain fused to high noble metal	5,450		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6751	Crown - porcelain fused to predominantly base metal	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6752	Crown - porcelain fused to noble metal	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6780	Crown - cast high noble metal	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6781	Crown - 3/4 cast predominantly base metal			$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6782	Crown - 3/4 cast noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6783	Crown - 3/4 porcelain/ceramic	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6790	Crown - full cast high noble metal	645		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6791	Crown - full cast predominantly base metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6792	Crown - full cast noble metal	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6793	Provisional retainer crown	90		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6794	Crown - titanium	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6920	Connector Bar	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6930	Recement fixed partial denture	75		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6940	Stress breaker	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6950	Precision attachment	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6975	Coping - metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6980	Fixed partial denture repair, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6999	Unspecified fixed prosthodontic procedure, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7111	Extraction, coronal remnants - deciduous tooth	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7140	Extraction, erupted tooth or exposed root	8,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7210	Surgical removal of erupted tooth	23,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7220	Removal of impacted tooth - soft tissue	6,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7230	Removal of impacted tooth - partially bony	23,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7240	Removal of impacted tooth - completely bony	24,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7241	Removal of impacted tooth - completely bony, with unusual surgical complications	2,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7250	Surgical removal of residual tooth roots (cutting procedure)	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7251	Coronectomy	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7252	Sinus augmentation via vertical approach	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7260	Oroantral fistula closure	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7261	Primary closure of a sinus perforation	35		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7270	Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7280	Surgical access of an unerupted tooth	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7283	Placement of device to facilitate eruption of impacted tooth	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7285	Biopsy of oral tissue - hard (bone, tooth)	70		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7286	Biopsy of oral tissue - soft	450		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7288	Brush biopsy - transepithelial sample collection	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7291	Transseptal fiberotomy/supra crestal fiberotomy, by report	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7293	Surgical placement: temporary anchorage device requiring surgical flap	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7294	Surgical placement: temporary anchorage device without surgical flap	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7295	Harvest of bone for use in autogenous grafting procedure	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7310	Alveoloplasty in conjunction with extractions - four or more teeth	80		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7311	Alveoloplasty in conjunction with extractions - one to three teeth	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7320	Alveoloplasty not in conjunction with extractions - four or more teeth	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7321	Alveoloplasty not in conjunction with extractions - one to three teeth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7350	Vestibuloplasty - ridge extension	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7410	Excision of benign lesion up to 1.25 cm	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7411	Excision of benign lesion greater than 1.25 cm	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7412	Excision of benign lesion, complicated	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7413	Excision of malignant lesion up to 1.25 cm	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7414	Excision of malignant lesion greater than 1.25 cm	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7415	Excision of malignant lesion, complicated	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7440	Excision of malignant tumor - lesion diameter up to 1.25 cm	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7441	Excision of malignant tumor - lesion diameter greater than 1.25 cm	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7450	Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7451	Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7460	Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7461	Removal of benign nonodontogenic cyst or tumor	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7465	Destruction of lesion(s) by physical or chemical method, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7471	Removal of lateral exostosis (maxilla or mandible)	45		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7472	Removal of torus palatinus	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7473	Removal of torus mandibularis	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7485	Surgical reduction of osseous tuberosity	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7490	Radical resection of maxilla or mandible	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7510	Incision and drainage of abscess - intraoral soft tissue	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7511	Incision and drainage of abscess - intraoral soft tissue	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7520	Incision and drainage of abscess - extraoral soft tissue	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7521	Incision and drainage of abscess - extraoral soft tissue	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7530	Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7540	Removal of reaction producing foreign bodies, musculoskeletal system	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7550	Partial ostectomy/sequestrectomy for removal of non-vital bone	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7560	Maxillary sinusotomy for removal of tooth fragment or foreign body	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7610	Maxilla - open reduction (teeth immobilized, if present)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7620	Maxilla - closed reduction (teeth immobilized, if present)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7630	Mandible - open reduction (teeth immobilized, if present)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7640	Mandible - closed reduction (teeth immobilized, if present)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7650	Malar and/or zygomatic arch - open reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7560	Malar and/or zygomatic arch - closed reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7670	Alveolus - closed reduction, may include stabilization of teeth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7671	Alveolus - open reduction, may include stabilization of teeth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7680	Facial bones - complicated reduction with fixation and multiple surgical approaches	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7710	Maxilla open reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7720	Maxilla - closed reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7730	Mandible - open reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7740	Mandible - closed reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7750	Malar and/or zygomatic arch - open reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7760	Malar and/or zygomatic arch - closed reduction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7770	Alveolus - open reduction stabilization of teeth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7771	Alveolus - closed reduction stabilization of teeth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7780	Facial bones - complicated reduction with fixation and multiple surgical approaches	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7810	Open reduction of dislocation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7820	Closed reduction of dislocation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7830	Manipulation under anesthesia	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7840	Condylectomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7850	Surgical discectomy, with/without implant	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7852	Disc repair	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7854	Synovectomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7856	Myotomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7858	Joint reconstruction	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7860	Arthrotomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7865	Arthroplasty	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7870	Arthrocentesis	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7871	Non-arthroscopic lysis and lavage	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7872	Arthroscopy - diagnosis with or without biopsy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7873	Arthroscopy - surgical: lavage and lysis of adhesions	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7874	Arthroscopy - surgical: disc repositioning and stabilization	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7875	Arthroscopy - surgical: synovectomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7876	Arthroscopy - surgical: discectomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7877	Arthroscopy - surgical: debridement	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7880	Occlusal orthotic device, by report	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7899	Unspecified TMD therapy, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7910	Suture of recent small wounds up to 5 cm	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7911	Complicated suture - up to 5 cm	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7912	Complicated suture - greater than 5 cm	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7920	Skin graft (identify defect covered, location, and type of graft)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7921	Collection and application of autologous blood concentrate product	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7944	Osteotomy - segmented or subapical	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7950	Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla	340		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7951	Sinus augmentation with bone or bone substitutes	140		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7952	Sinus augmentation via a vertical approach	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7953	Bone replacement graft for ridge preservation - per site	700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7955	Repair of maxillofacial soft and/or hard tissue defect	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7960	Frenulectomy (frenectomy or frenotomy) - separate procedure	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7963	Frenuloplasty	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7970	Excision of hyperplastic tissue - per arch	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7971	Excision of pericoronal gingiva	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7972	Surgical reduction of fibrous tuberosity	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7980	Sialolithotomy	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7981	Excision of salivary gland, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7982	Sialodochoplasty	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7983	Closure of salivary fistula	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7990	Emergency tracheotomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7991	Coronoidectomy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7995	Synthetic graft - mandible or facial bones, by report	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7996	Implant - mandible for augmentation purposes, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7997	Appliance removal (not by dentist who placed appliance), includes removal of archbar	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D7999	Unspecified oral surgery procedure, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8040	Limited orthodontic treatment of the adult dentition	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8090	Comprehensive orthodontic treatment of the adult dentition	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8210	Removable appliance therapy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8220	Fixed appliance therapy	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8660	Pre-orthodontic treatment visit	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8670	Periodic orthodontic treatment visit (as part of contract)	1,800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8680	Orthodontic retention	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8691	Repair of orthodontic appliance	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8692	Replacement of lost or broken retainer	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D8999	Unspecified orthodontic procedure, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9110	Palliative (emergency) treatment of dental pain - minor procedure	1,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9120	Fixed partial denture sectioning	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9210	Local anesthesia not in conjunction with operative or surgical procedures	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9211	Regional block anesthesia	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9212	Trigeminal division block anesthesia	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9215	Local anesthesia	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9220	Deep sedation/general anesthesia - first 30 minutes	13,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9221	Deep sedation/general anesthesia - each additional 15 minutes	12,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9230	Analgesia, anxiolysis, inhalation of nitrous oxide	2,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9241	Intravenous conscious sedation/analgesia - first 30 minutes	11,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9242	Intravenous conscious sedation/analgesia - each additional 15 minutes	15,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9248	Non-intravenous conscious sedation	400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9310	Consultation	7,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9420	Hospital call	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9430	Office visit for observation - no other services performed	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9440	Office visit - after regularly scheduled hours	110		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9450	Case presentation, detailed and extensive treatment planning	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9610	Therapeutic parenteral drug, single administration	4,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9612	Therapeutic parenteral drugs, two or more administrations, different medications	1,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9630	Other drugs and/or medicaments, by report	1,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9910	Application of desensitizing medicament	750		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9911	Application of desensitizing resin for cervical and/or root surface, per tooth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9920	Behavior management, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9930	Treatment of complications - unusual circumstances, by report	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9940	Occlusal guard, by report	2,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9941	Fabrication of athletic mouthguard	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9942	Repair and/or reline of occlusal guard	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9950	Occlusion analysis - mounted case	125		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9951	Occlusal adjustment - limited	210		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9952	Occlusal adjustment - complete	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9970	Enamel microabrasion	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9971	Odontoplasty 1-2 teeth, includes removal of enamel projections	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9974	Internal bleaching - per tooth	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D9999	Unspecified adjunctive procedure, by report	7,900		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
Grand Total				$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0	Column T Total
													$ - 0	Row 506 Total

&CAttachment J-22 CDT Pricing

File details come from the government source that posted it. Updated Nov 14, 2017.