Exhibit A CDT Codes.v3.xlsx

XLSX spreadsheet 2 MB Posted Nov 14, 2019

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

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Written by GovTribe AI · Dec 27, 2023

This document provides a draft request for proposal (RFP) for the Active Duty Dental Program 3 (ADDP3) contract. The Defense Health Agency (DHA) intends to award a single-award indefinite delivery/indefinite quantity contract for fixed unit price dental services to support the TRICARE program for active duty service members and beneficiaries overseas. The potential 9.5-year contract would consolidate domestic and overseas dental requirements and include a transition period, 7 option years for service delivery, and an optional 6-month extension. The draft RFP sections and attachments provide the statement of work, contract line items, and pricing table with estimated quantities for current dental procedure codes. DHA requests industry feedback on the draft RFP by November 15th to improve the acquisition approach. Questions or comments should be submitted to the contracting officer via email. No proposal submissions or contact with other individuals is authorized in response to this pre-solicitation notice. DHA aims to issue a formal RFP on beta.sam.gov in early 2020.

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Other files for this federal contract opportunity

Other files attached to Active Duty Dental Program 3 (ADDP3), newest first.
File	Type	Posted
J-18 Draft ADDP QASP.docx	DOCX document	Nov 14, 2019
ADDP3 RFI 1.docx	DOCX document	Nov 14, 2019
J-17 Guarantee Agreement for Corporate Guarantor v1.pdf	PDF	Nov 14, 2019
J-20 Ordering Instructions for Data Files v1.docx	DOCX document	Nov 14, 2019
J-6 Similar or Alternate Dental Procedure Codes Accepted Ref & Auths v2.docx	DOCX document	Nov 14, 2019
J-4 Procedures for Remote ADSM Categories v2.docx	DOCX document	Nov 14, 2019
J-13 Transition-In v2.docx	DOCX document	Nov 14, 2019
J-14 Transition-Out and Residual Services v2.docx	DOCX document	Nov 14, 2019
J-19c Sample Client Authorization Letter v1.docx	DOCX document	Nov 14, 2019
J-19b Sample Past Performance Consent Letter v1.docx	DOCX document	Nov 14, 2019
J-3a Program Ops v2.docx	DOCX document	Nov 14, 2019
J-8 DSPOC Review Codes v2.docx	DOCX document	Nov 14, 2019
ADDP3 Additional Questions and Comments.xlsx	XLSX spreadsheet	Nov 14, 2019
J-11 Dental Plan Codes v1.docx	DOCX document	Nov 14, 2019
J-10 Uniformed Services DTFs DMIS ID v1.docx	DOCX document	Nov 14, 2019
J-1 Definitions v1.docx	DOCX document	Nov 14, 2019
ADDP3 DRAFT Sec B-M.pdf	PDF	Nov 14, 2019
J-3b Program Ops OCONUS v2.docx	DOCX document	Nov 14, 2019
J-9 DSPOC Materials Checklist v2.docx	DOCX document	Nov 14, 2019
J-7b DoD Oral Health Readiness Classification v1.docx	DOCX document	Nov 14, 2019
J-5a Instructions for Remote ADSM Dental Care v2.docx	DOCX document	Nov 14, 2019
J-7a DD2813 Exam Screen v1.pdf	PDF	Nov 14, 2019
J-5b Sample Command Memo v1.docx	DOCX document	Nov 14, 2019
J-19a Past Performance Questionnaire v1.docx	DOCX document	Nov 14, 2019
J-3c Program Ops Data v2.docx	DOCX document	Nov 14, 2019
J-2 Benefits Exclusions and Limitations v2.docx	DOCX document	Nov 14, 2019
J-12 MDR Data Elements Layout v2.docx	DOCX document	Nov 14, 2019

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CONUS

	Exhibit A - CONUS
TRICARE ACTIVE DUTY DENTAL PROGRAM - HT9402-20-R-0001 - CDT PRICING TABLE
			Option Period 1		Option Period 2		Option Period 3		Option Period 4		Option Period 5		Option Period 6		Option Period 7		Estimated Total
Procedure Code	Description	CONUS Estimated Quantity For Each OP	Unit Price	Extended Price	Unit Price	Extended Price	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	62,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0140	Limited oral evaluation - problem focused	53,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0150	Comprehensive oral evaluation - new or established patient	32,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0160	Detailed and extensive oral evaluation - problem focused, by report	800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0170	Re-evaluation - limited, problem focused (established patient, not post-operative visit)	350		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0171	re-evaluation - post-operative office visit	45		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0180	Comprehensive periodontal evaluation - new or established patient	2,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0190	screening of a patient	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0191	assessment of a patient	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0210	Intraoral - complete series of radiographic images	16,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0220	Intraoral - periapical first radiographic image	43,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0230	Intraoral - periapical each additional radiographic image	32,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0240	Intraoral - occlusal radiographic image	140		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0250	Extraoral - 2D projection radiographic image created using a stationary radiation source, and detector	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
DO251	Extraoral posterior dental radiographic image	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0270	Bitewing - single radiographic image	4,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0272	Bitewings - two radiographic images	4,600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0273	Bitewings - three radiographic images	220		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0274	Bitewings - four radiographic images	50,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0277	Vertical bitewings - 7 to 8 radiographic images	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0290	Posterior-anterior or lateral skull and facial bone survey radiographic image	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0310	Sialography	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0320	Temporomandibular joint arthrogram, including injection	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0321	Other temporomandibular joint radiographic images, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0322	Tomographic survey	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0330	Panoramic radiographic image	25,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0340	2D cephalometric radiographic image - acquisition, measurement and analysis	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0350	Oral/facial photographic image obtained intraorally or extraorally	450		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0351	3D photographic image	45		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0364	Cone beam CT capture and interpretation with limited field of view - less than one whole jaw	3,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0365	Cone beam CT capture and interpretation with limited field of view of one full dental arch - mandible	550		$ - 0		$ - 0		$ - 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	400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0367	Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium	1,800		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0368	Cone beam CT capture and interpretation for TMJ series including two or more exposures	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0369	Maxillofacial MRI capture and interpretation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0370	Maxillofacial ultrasound capture and interpretation	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0371	Sialoendoscopy capture and interpretation	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0380	Cone beam CT image capture with limited field of view - less than one whole jaw	550		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0381	Cone beam CT image capture with limited field of view of one full dental arch - mandible	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0382	Cone beam CT imagae capture with limited field of view of one full dental arch - maxilla, with or without cranium	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0383	Cone beam CT image capture with field of view of both jaws, with or without cranium	450		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0384	Cone beam CT image capture for TMJ series including two or more exposures	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0385	Maxillofacial MRI image capture	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0386	Maxillofacial ultrasound image capture	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0391	Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report	45		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0393	Treatment simulation using 3D image volume	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0394	Digital subtraction of two or more images or image volumes of the same modality	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0395	Fusion of two or more 3D image volumes of one or more modalities	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0411	HbA1c in-office point of service testing	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0412	Blood glucose level test - in-office using a glucose meter	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0414	Laboratory processing of microbial speciment to include culture and sensitivity studies, preparation and transmission of written report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0415	Collection of microorganisms for culture and sensitivity	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0416	Viral culture	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0417	Collection and preparation of saliva sample for laboratory diagnostic testing	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0418	Analysis of saliva sample	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0419	Assessment of salivary flow by measurement	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0422	Collection and preparation of genetic sample material for laboratory anlysis and report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0423	Genetic test for susceptibility to deseasees - specimen analysis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0425	Caries susceptibility tests	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0431	Adjunctive pre-diagnostic test that aids in the detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0460	Pulp vitality tests	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0470	Diagnostic casts	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0472	Accession of tissue, gross examination preparation and transmission of written report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0473	Accession of tissue, gross and microscopic examination, preparation and transmission of written report	5		$ - 0		$ - 0		$ - 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	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0475	Decalcification procedure	3		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0476	Special stains for microorganisms	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0477	Special stains, not for microorganisms	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0478	Imminohistochemical stains	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0479	Tissue in-situ hybridization, including interpretation	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0480	Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0481	Electron microscopy - diagnostic	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0482	Direct immunofluorescence	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0483	Indirect immunofluorescence	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0484	Consultation on slides prepared elsewhere	5		$ - 0		$ - 0		$ - 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		$ - 0	$ - 0
D0486	Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report	3		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0502	Other oral pathology procedures, by report	3		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0600	Non-ionizingdiagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin and cementum	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0601	Caries risk assessment and documentation, with a finding of low risk	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0602	Caries risk assessment and documentation, with a finding of moderate risk	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0603	Caries risk assessment and documentation, with a finding of high risk	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D0999	Unspecified diagnostic procedure, by report	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1110	Prophylaxis - adult	100,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1206	Topical application of fluoride varnish	32,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1208	Topical application of fluoride	18,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1310	Nutritional counseling for control of dental disease	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1320	Tobacco counseling for the control and prevention of oral disease	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1330	Oral hygiene instructions	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1351	Sealant - per tooth	1,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1352	Preventive resin restoration in a moderate to high caries risk patient - permanent tooth	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1353	sealant repair - per tooth	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1354	Interim caries arresting medicament appplication-per tooth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1510	Space maintainer - fixed - unilateral - per quadrant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1515	Space maintainer - fixed - bilateral	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1516	space maintainer - fixed - bilateral, maxillary	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1517	space maintainer - fixed - bilateral, mandibular	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1520	Space maintainer - removable - unilateral - per quadrant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1525	Space maintainer - removable - biilateral	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1526	space maintainer - removable - bilateral, maxillary	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1527	space maintainer - removable - bilateral, mandibular	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1551	Re-cement or re-bond bilateral space maintainer - maxillary	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1552	Re-cement or re-bond bilateral space maintainer - mandibular	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1553	Re-cement or re-bond unilateral space maintainer - per quadrant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1556	Removal of fixed unilateral space maintainer - per quadrant	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1557	Removal of fixed bilateral space maintainer - maxillary	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1558	Removal of fixed bilateral space maintainer - mandibular	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1575	Distal shoe space maintainer-fixed-unilateral - per quadrant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D1999	unspecified preventive procedure, by report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2140	Amalgam - one surface, primary or permanent	4,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2150	Amalgam - two surfaces, primary or permanent	8,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2160	Amalgam - three surfaces, primary or permanent	3,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2161	Amalgam - four or more surfaces, primary or permanent	700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2330	Resin-based composite - one surface, anterior	4,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2331	Resin-based composite - two surfaces, anterior	6,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2332	Resin-based composite - three surfaces, anterior	4,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2335	Resin-based composite - four or more surfaces or involving incisal angle (anterior)	2,750		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2390	Resin-based composite crown, anterior	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2391	Resin-based composite - one surface, posterior	23,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2392	Resin-based composite - two surfaces, posterior	35,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2393	Resin-based composite - three surfaces, posterior	13,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2394	Resin-based composite - four or more surfaces, posterior	2,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2410	Gold foil - one surface	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2420	Gold foil - two surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2430	Gold foil - three surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2510	Inlay - metallic - one surface	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2520	Inlay - metallic - two surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2530	Inlay - metallic - three or more surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2542	Onlay - metallic - two surfaces	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2543	Onlay - metallic - three surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2544	Onlay - metallic - four or more surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2610	Inlay - porcelain/ceramic - one surface	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2620	Inlay - porcelain/ceramic - two surfaces	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2630	Inlay - porcelain/ceramic - three or more surfaces	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2642	Onlay - porcelain/ceramic - two surfaces	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2643	Onlay - porcelain/ceramic - three surfaces	35		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2644	Onlay - porcelain/ceramic - four or more surfaces	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2650	Inlay - resin-based composite - one surface	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2651	Inlay - resin-based composite - two surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2652	Inlay - resin-based composite - three or more surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2662	Onlay - resin-based composite - two surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2663	Onlay - resin-based composite - three surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2664	Onlay - resin-based composite - four or more surfaces	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2710	Crown - resin - based composite (indirect)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2712	Crown - 3/4 resin-based composite (indirect)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2720	Crown - resin with high noble metal	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2721	Crown - resin with predominantly base metal	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2722	Crown - resin with noble metal	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2740	Crown - porcelain/ceramic	12,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2750	Crown - porcelain fused to high noble metal	4,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2751	Crown - porcelain fused to predominantly base metal	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2752	Crown - porcelain fused to noble metal	700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2753	Crown - porcelain fused to titanium and titanium alloys	2,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2780	Crown - 3/4 cast high noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2781	Crown - 3/4 cast predominantly base metal	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2782	Crown - 3/4 cast noble metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2783	Crown - 3/4 porcelain/ceramic	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2790	Crown - full cast high noble metal	2,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2791	Crown - full cast predominantly base metal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2792	Crown - full cast noble metal	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2794	Crown - titanium and titanium alloys	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2799	Provisional crown - further treatment or completion of diagnosis necessary prior to final impression	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2910	Recement inlay, onlay, or partial coverage restoration	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2915	Recement cast or prefabricated post and core	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2920	Recement crown	600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2921	reattachment of tooth fragment, incisal edge or cusp	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2931	Prefabricated stainless steel crown - permanent tooth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2932	Prefabricated resin crown	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2933	Prefabricated stainless steel crown with resin window	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2940	Protective restoration	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2949	restorative foundation for an indirect restoration	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2950	Core buildup, including any pins when required	9,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2951	Pin retention - per tooth, in addition to restoration	75		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2952	Post and core in addition to crown, indirectly fabricated	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2953	Each additional indirectly fabricated post - same tooth	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2954	Prefabricated post and core in addition to crown	1,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2955	Post removal (not in conjunction with endodontic therapy)	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2957	Each additional prefabricated post - same tooth	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2960	Labial veneer (resin laminate) - chairside	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2961	Labial veneer (resin laminate) - laboratory	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2962	Labial veneer (porcelain laminate) - laboratory	125		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2971	Additional procedures to construct new crown under existing partial denture framework	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2975	Coping	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2980	Crown repair, necessitated by restorative material failure	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2981	Inlay repair necessitated by restorative material failure	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2982	Onlay repair necessitated by restorative material failure	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2983	Veneer repair necessitated by restorative material failure	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2990	Resin infiltration of incipient smooth surface lesions	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D2999	Unspecified restorative procedure, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3110	Pulp cap - direct (excluding final restoration)	575		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3120	Pulp cap - indirect (excluding final restoration)	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3220	Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament	65		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3221	Pulpal debridement, primary and permanent teeth	300		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3222	Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3310	Endodontic therapy - anterior (excluding final restoration)	1,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3320	Endodontic therapy - premolar (excluding final restoration)	2,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3330	Endodontic therapy - molar tooth (excluding final restoration)	6,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3331	Treatment of root canal obstruction, non-surgical access	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3332	Incomplete endodontic therapy, inoperable, unrestorable or fractured tooth	125		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3333	Internal root repair of perforation defects	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3346	Retreatment of previous root canal therapy - anterior	350		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3347	Retreatment of previous root canal therapy - premolar	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3348	Retreatment of previous root canal therapy - molar	1,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3351	Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3352	Apexification/recalcification - interim medication replacement	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3353	Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3355	pulpal regeneration - initial visit	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3356	pupal regeneration - interim medication replacement	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3357	pulpal regeneration - completion of treatment	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3410	Apicoectomy/periradicular surgery - anterior	175		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3421	Apicoectomy - premolar (first root)	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3425	Apicoectomy - molar (first root)	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3426	Apicoectomy (each additional root)	120		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3427	periradicular surgery without apicoectomy	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3428	bone graft in conjunction with periradicular surgery - per tooth, single site	125		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3429	bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3430	Retrograde filling - per root	450		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3431	biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3432	guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3450	Root amputation - per root	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3460	Endodontic endosseous implant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3470	Intentional reimplantation (including necessary splinting)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3910	Surgical procedure for isolation of tooth with rubber dam	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3920	Hemisection (including any root removal), not including root canal therapy	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3950	Canal preparation and fitting of preformed dowel or post	50		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D3999	Unspecified endodontic procedure, by report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4210	Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant	80		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4212	Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth	70		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4230	Anatomical crown exposure - four or more contiguous teeth or tooth bounded tooth spaces per quadrant	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4231	Anatomical crown exposure - one to three teeth or tooth bounded tooth spaces per quadrant	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4240	Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4241	Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4245	Apically positioned flap	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4249	Clinical crown lengthening - hard tissue	750		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4260	Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant	1,200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4261	Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant	700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4263	Bone replacement graft -retained natural tooth- first site in quadrant	1,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4264	Bone replacement graft - retained natural tooth-each additional site in quadrant	400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4265	Biologic materials to aid in soft and osseous tissue regeneration	850		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4266	Guided tissue regeneration - resorbable barrier, per site	1,400		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4267	Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)	260		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4268	Surgical revision procedure, per tooth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4270	Pedicle soft tissue graft procedure	125		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4273	Autogenous connective tissue graft procedure (including donor and recipient surgical sites)first tooth, implant or edentulous tooth position in graft	700		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4274	Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)	130		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4275	Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant or edentulous tooth position in graft	170		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4276	Combined connective tissue and double pedicle graft, per tooth	125		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4277	Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or dentulous tooth position in graft	175		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4278	Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or dentulous tooth position in same graft site	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4283	Autogenous connective tissue graft pocedure (including recipient surgical site and donor material) - each additional contguous tooth, implant or edentulous tooth position in same graft site	250		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4285	Non-autogenous connective tissue graft pocedure (including recipient surgical site and donor material) - each additional contguous tooth, implant or edentulous tooth position in same graft site	165		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4320	Provisional splinting - intracoronal	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4321	Provisional splinting - extracoronal	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4341	Periodontal scaling and root planing - four or more teeth per quadrant	12,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4342	Periodontal scaling and root planing - one to three teeth per quadrant	2,500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4346	Scaling in presence of generalized moderate or severe gingival inflammation-full mouth, after oral evaluation	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4355	Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit	1,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4381	Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4910	Periodontal maintenance	10,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4920	Unscheduled dressing change (by someone other than treating dentist or their staff)	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4921	gingival irrigation - per quadrant	127		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D4999	Unspecified periodontal procedure, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5110	Complete denture - maxillary	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5120	Complete denture - mandibular	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5130	Immediate denture - maxillary	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5140	Immediate denture - mandibular	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5211	Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5212	Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5213	Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5214	Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)	60		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5221	Immediate maxillary partial denture - resin base(including retentive/clasping materials, rests and teeth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5222	Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5223	Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5224	Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5225	Maxillary partial denture - flexible base (including any clasps, rests and teeth)	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5226	Mandibular partial denture - flexible base (including any clasps, rests and teeth)	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5281	Removable unilateral partial denture - one piece cast metal (including clasps and teeth)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5282	Removable unilateral partial denture - one piece cast metal (including clasps and teeth), maxillary	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5283	Removable unilateral partial denture - one piece cast metal (including clasps and teeth), mandibular	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5284	Removable unilateral partial denture - one piece flxible base (including clasps and teeth) - per quadrant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5286	Removable unilateral partial denture - one piece resin (including clasps and teeth) - per quadrant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5410	Adjust complete denture - maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5411	Adjust complete denture - mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5421	Adjust partial denture - maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5422	Adjust partial denture - mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5511	Repair broken complete denture base, mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5512	Repair broken complete denture base, maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5520	Replace missing or broken teeth - complete denture (each tooth)	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5611	Repair resin partial denture base, mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5612	Repair resin partial denture base, maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5621	Repair cast partial framework, mandibular	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5622	Repair cast partial framework, maxillary	3		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5630	Repair or replace broken clasp retentive clasping materials - per tooth	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5640	Replace broken teeth - per tooth	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5650	Add tooth to existing partial denture	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5660	Add clasp to existing partial denture - per tooth	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5670	Replace all teeth and acrylic on cast metal framework (maxillary)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5671	Replace all teeth and acrylic on cast metal framework (mandibular)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5710	Rebase complete maxillary denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5711	Rebase complete mandibular denture	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5720	Rebase maxillary partial denture	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5721	Rebase mandibular partial denture	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5730	Reline complete maxillary denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5731	Reline complete mandibular denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5740	Reline maxillary partial denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5741	Reline mandibular partial denture (chairside)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5750	Reline complete maxillary denture (laboratory)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5751	Reline complete mandibular denture (laboratory)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5760	Reline maxillary partial denture (laboratory)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5761	Reline mandibular partial denture (laboratory)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5810	Interim complete denture (maxillary)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5811	Interim complete denture (mandibular)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5820	Interim partial denture (maxillary)	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5821	Interim partial denture (mandibular)	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5850	Tissue conditioning, maxillary	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5851	Tissue conditioning, mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5862	Precision attachment, by report	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5863	overdenture - complete maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5864	overdenture - partial maxillary	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5865	overdenture - complete mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5866	overdenture - partial mandibular	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5867	Replacement of replaceable part of semi-precision or precision attachment ( male or female component)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5875	Modification of removable prosthesis following implant surgery	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5876	add metal substructure to acrylic full denture (per arch)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5899	Unspecified removable prosthodontic procedure, by report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5911	Facial moulage (sectional)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5912	Facial moulage (complete)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5913	Nasal prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5914	Auricular prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5915	Orbital prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5916	Ocular prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5919	Facial prosthesis	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5922	Nasal septal prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5923	Ocular prosthesis, interim	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5924	Cranial prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5925	Facial augmentation implant prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5926	Nasal prosthesis, replacement	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5927	Auricular prosthesis, replacement	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5928	Orbital prosthesis, replacement	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5929	Facial prosthesis, replacement	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5931	Oburator prosthesis, surgical	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5932	Obturator prosthesis, definitive	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5933	Obturator prosthesis, modification	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5934	Mandibular resection prosthesis with guide flange	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5935	Mandibular resection prosthesis without guide flange	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5936	Obturator prosthesis, interim	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5937	Trismus appliance (not for TMD treatment)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5953	Speech aid prosthesis, adult	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5954	Palatal augmentation prosthesis	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5955	Palatal lift prosthesis, definitive	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5958	Palatal lift prosthesis, interim	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5959	Palatal lift prosthesis, modification	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5960	Speech aid prosthesis, modification	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5982	Surgical stent	175		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5983	Radiation carrier	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5984	Radiation shield	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5985	Radiation cone locator	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5986	Fluoride gel carrier	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5987	Commissure splint	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5988	Surgical splint	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5991	vesiculobullous disease medicament carrier	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5992	Adjust maxillofacial prosthetic appliance, by report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5993	Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5994	periodontal medicament carrier with peripheral seal - laboratory processed	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D5999	Unspecified maxillofacial prosthesis, by report	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6010	Surgical placement of implant body: endosteal implant	2,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6011	second stage implant surgery	500		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6012	Surgical placement of interim implant body for transitional prosthesis; endosteal implant	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6013	surgical placement of mini implant	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6040	Surgical placement: eposteal implant	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6050	Surgical placement: transosteal implant	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6051	Interim abutment	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6052	semi-precision attachment abutment	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6053	Implant/abutment supported removable denture for completely edentulous arch	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6054	Implant/abutment supported removable denture for partially edentulous arch	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6055	Connecting bar - implant supported or abutment supported	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6056	Prefabricated abutment - includes modification and placement	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6057	Custom fabricated abutment - includes placement	1,000		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6058	Abutment supported porcelain/ceramic crown	600		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6059	Abutment supported porcelain fused to metal crown (high noble metal)	240		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6060	Abutment supported porcelain fused to metal crown ( predominantly base metal)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6061	Abutment supported porcelain fused to metal crown (noble metal)	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6062	Abutment supported cast metal crown (high noble metal)	10		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6063	Abutment supported cast metal crown (predominantly base metal)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6064	Abutment supported cast metal crown (noble metal)	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6065	Implant supported porcelain/ceramic crown	150		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6066	Implant supported crown - porcelain fused to high noble alloys	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6067	Implant supported crown - high noble alloys	15		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6068	Abutment supported retainer for porcelain/ceramic FPD	40		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6069	Abutment supported retainer for porcelain fused to metal FPD (high noble metal)	20		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6070	Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6071	Abutment supported retainer for porcelain fused to metal FPD (noble metal)	15		$ - 0		$ - 0		$ - 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		$ - 0	$ - 0
D6073	Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6074	Abutment supported retainer for cast metal FPD (noble metal)	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6075	Implant supported retainer for ceramic FPD	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6076	Implant supported retainer for FPD - porcelain fused to high noble alloys	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6077	Implant supported retainer for metal FPD - high noble alloys	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6078	Implant/abutment supported fixed denture for completely edentulous arch	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6079	Implant/abutment supported fixed denture for partially edentulous arch	2		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6080	Implant maintenance procedures when prosthesis are removed and reinserted, including cleansing of prosthesis and abutments	100		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6081	Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure	5		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6082	Implant suppported crown - porcelain fused to predominantly base allouys	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6083	Implant supported crown - porcelain fused to noble alloys	275		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6084	Implant supported crown - porcelain fused to titanium and titanium alloys	200		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6085	Provisional implant crown	25		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6086	Implant supported crown - predominantly base alloys	1		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6087	Implant supported crown - noble alloys	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0
D6088	Implant supported crown - titanium and titanium alloys	30		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0		$ - 0	$ - 0

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Nov 14, 2019.