~ Descriptors that have been revised since the last edition. ^ Revision in the nomenclature

Transcription

1 D0100-D0999 I. Diagnostic The codes in this section have been revised to recognize the cognitive skills necessary for patient evaluation. diagnosis and treatment planning (casts included) $10.00 $40.00 $ for complex restorative care Graduate prosthodontics casts included $ D periodic oral examination $40.00 $40.00 $40.00 $ D0140 limited oral evaluation problem focused $50.00 $50.00 $0.00 $ typically patients receiving this type of exam have been referred for a specific D comprehensive oral exam usually paid once lifetime per provider $50.00 $50.00 $50.00 $ D detailed and extensive oral eval/problem focused, variable (second opinion code) $50.00 $ $0.00 $ DO170 New code re-evaluation-limited, problem focused, established patient, not a postoperative visit, $50.00 Assessing the status of previously existing condition. For example: a traumatic injury where no treatment was rendered but patient needs follow upmonitoring evaluation for undiagnosed continuing pain soft tissue lesion requiring follow-up evaluation D0180 comprehensive periodontal evaluation - new or established patient $50.00 RADIOGRAPHS Clinical examination for new intraoral radiographs should occur at least once every 6-8 months for children, months for adults. This decision is based upon clinical findings, caries rate, etc. D intraoral complete series includes bite wing, once every five years $30.00 $30.00 $30.00 $ D intraoral -periapical first film $12.00 $12.00 $20.00 $ D intraoral-periapical each additional film $8.00 $8.00 $10.00 $ D intraoral occlusal film $12.00 $12.00 $20.00 $ D extraoral first film $25.00 $25.00 $25.00 $ D extraoral each additional film $25.00 $25.00 $25.00 $ D one bitewing x-ray $12.00 $12.00 $15.00 $ D two films-bite wings once/yr for adults, twice/yr for children $20.00 $20.00 $30.00 $ D four films-bite wings once/yr for adults, twice/yr for children $24.00 $24.00 $40.00 $ D0277 vertical bitewings - 7 to 8 films $30.00 D0290 posterior-anterior lateral skull and facial bone survey film $32.00 $32.00 $32.00 $ D0310 x-ray,sialography $65.00 $65.00 $0.00 $ D temporomandibular joint arthogram including injection $0.00 $ $0.00 $ D0321 other TMJ films variable - NOT A DELTA BENEFIT $ $ $0.00 $ D x-ray tomographic survey without report, lateral view:open,closed (serial view) $ $ $0.00 $ D panoramic film $30.00 $50.00 $ $ D cephalometric film, DELTA ONLY IF THEY HAVE ORTHO BENEFIT $50.00 $50.00 $ $ D New code oral/facial images (includes intra and extraoral images) $8.00 $8.00 $0.00 $7.00 This includes both traditional photographs and images obtained by intraoral cameras. These image should be part of the patient's record. 1

2 DUPLICATION OF RADIOGRAPGHS AND/OR RECORDS See office of Patient Records for policy and fees. TEST AND LABORATORY EXAMINATIONS D0415 bacteriologic studies for determination of pathologic agents $60.00 $ $0.00 $ may include but not limited to test for susceptibility to periodontal disease D0425 caries susceptibility tests $10.00 $0.00 $15.00 $ not to be used for carious dentin staining D0460 pulp vitality tests $5.00 $25.00 $5.00 $ includes multiple teeth and contralateral comparison(s) D0470 diagnostic casts $25.00 $15.00 $ diagnostic casts mounted with face bow and CJR record $25.00 diagnostic casts writing and mounting $ diagnostic occlusal splint $ D0472 accession of tissue, gross examination, preparation and transmission or written report D0473 accession of tissue, gross and microscopic examination, preparation and transmission or written report accession of tissue, gross and microscopic examination, including assessment of D0474 surgical margins for presence of disease, preparation and transmission of written D0480 processing and interpretation of cytologic smears, including the preparation and transmission of written report D0501 other oral path procedures,variable variable variable $0.00 $ other oral path procedures,variable laboratory examination (hemotology, urinalysis, etc.) D0502 unspecified diagnostic procedure, variable variable $ $ D0999 unspecified diagnostic procedure, variable variable variable $0.00 $ D1000-D1999 II. PREVENTIVE DENTAL PROPHYLAXIS D prophy-adult, usually twice a year some plans yearly $40.00 $60.00 $0.00 $ beneficiaries age 13 and older D prophy-child $30.00 $40.00 $40.00 $ beneficaries thru the age of 12 Topical fluoride treatment (office procedure) D1201 topical application of flouride including prophaylaxis-including child-up to 14 years of age $40.00 $0.00 $ beneficiaries 5 and under $ beneficaries age 6 thru 17 $40.00 D1203 topical application of flouride prophylaxis not included-child $10.00 $25.00 $25.00 $ D1204 topical application of flouride prophylaxis not included-adult $15.00 $15.00 $0.00 $ D1205 topical application of fluoride (including prophylaxis);adult $55.00 $65.00 $0.00 $

3 OTHER PREVENTIVE SERVICES D1310 nutritional counseling for control of dental disease $5.00 $10.00 $5.00 $ D1320 tobacco counseling for the control and prevention of oral disease N/C N/C N/C $ D1330 oral hygeine instructions-not A BENEFIT FOR DELTA $6.00 $10.00 $6.00 $ D1351 sealant application-per tooth (crown or root) $25.00 $0.00 $ permanent first molars to age 21 $ permanent second molars to age 21 $22.00 SPACE MAINTENANCE (PASSIVE APPLIANCES) D space maintainer-fixed-unilateral band and loop $ $0.00 $ $ distal shoe $ $0.00 $ $ D space maintainer-fixed-bilateral, nan holding arch, lowe lingual holding arch $ $ $ $ D space maintainer-removable-unilateral, Hawley appliance maxillary or mandibular type. $ $ $ $ D space maintainer-removable-bilateral $ $ $ $ D1550 recementation of space maintainer $15.00 $10.00 $10.00 $ D2000-D2999 III. RESTORATIVE AMALGAM RESTORATIONS (INCLUDING POLISHING) D amalgam - 1 surface, primary or permanent $45.00 $45.00 $60.00 $ D amalgam - 2 surfaces, primary or permanent $55.00 $60.00 $70.00 $ D amalgam - 3 surfaces, primary or permanent $65.00 $85.00 $80.00 $ D amalgam - 4 surfaces, primary or permanent $75.00 $ $85.00 $ Resin-based composite refers to a broad category of materials including but not limited to compositie, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin based bonding agents), liners and bases and curing, are included as part of the restoration. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used they should be reported separately (see D2951) cal must be lab processed, requieres x-ray and documentation D composite - 1 surface anterior primary or permanent $55.00 D composite - 2 surface anterior primary or permanent $55.00 D composite - 3 surface anterior primary or permanent $55.00 D composite - 4 or more surf. or involving the incisal angle prim or perm $95.00 D resin-based composite crown - anterior $ D resin-based composite - one surface, posterior $55.00 $ $85.00 $ D resin-based composite - two surfaces, posterior $85.00 $ $85.00 $ D resin-based composite - three surfaces, posterior $90.00 $ $85.00 $ D resin-based composite - four or more surfaces, posterior $90.00 $ $ $

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5 Gold Foil Restorations D2410 gold foil one surface $80.00 $0.00 $0.00 $ D2420 gold foil two surfaces $ $0.00 $0.00 $ D2430 gold foil three surfaces $ $0.00 $0.00 $ INLAY/ONLAY RESTORATIONS D2510 inlay metallic one surface $ $ $0.00 $ D2520 inlay metallic two surfaces $ $ $0.00 $ D2530 inlay metallic three or more surfaces $ $ $0.00 $ D2542 onlay - porcelain/ceramic - two surfaces $ $ $0.00 $ requires x-ray and narrative D2543 onlay metallic three surfaces, requires x-ray and narrative documentation required $ $ $0.00 $ D2544 onlay metallic four or more surfaces, requires x-ray and narrative documentation required $ $ $0.00 $ Porcelain/ceramic inlays presently include either ALL ceramic or porcelain inlays. D2610 Inlay-porcelain/ceramic-1 surfaces $ $ $0.00 $ D2620 inlay-porcelain/ceramic-2 surfaces $ $ $0.00 $ D2630 Inlay-porcelain/ceramic-3 surfaces $ $ $0.00 $ D2642 onlay-porcelain/ceramic-class II - 2 surfaces $ $ $0.00 $ D2643 onlay-porcelain/ceramic - Class III - 3 surfaces $ $ $0.00 $ D2644 onlay-porcelain/ceramic -four or more surfaces $ $ $0.00 $ D2650 Inlay -composite/resin - 1 surface (laboratory) $ $ $45.00 $ D2651 Inlay -composite/resin - 2 surface (laboratory) $ $ $50.00 $ D2652 Inlay -composite/resin - 3 or more surfaces (laboratory) $ $ $60.00 $ D2662 onlay - resin-based composite - class II - 2 surfaces $ $ $0.00 $ D2663 onlay - resin-based composite - 3 surfaces $ $ $0.00 $ D2664 onlay - resin-based composite - 4 or more surfaces $ $ $0.00 $ Crowns-Single Restorations Only Crown lab processed resin, not temporary, not on children The alloys are defined on the basis of the percentage of noble metal content: high noble -Gold (AU) Palladium (Pd), and/or Platinum (Pt) >60% (with at least 40% Au); noble - Gjold (Au), Palladium Palladium (Pd), and/or Platinum (Pt) >60% (with at least 40% Au); noble - Gjold (Au), Palladium (Pd), and/or Platinum (Pt) > 25%; predominantly base - Gold (Au), Palladium (Pd), and or Platinum (Pt) < 25%. Porcelain/ceramic crowns include all ceramic, porcelain, polymer-reinforced porcelain and porcelain fused to metal crowns. Resin crowns and resin metal crowns include all reinforced heat and/or pressure-cured resin materials. D crown-resin (indirect) $ $ $0.00 $ D crown-resin with high noble metal** $ $ $0.00 $ D2721 crown-resin with predominantly base metal $ $ $0.00 $ D2722 crown-resin with noble metal** $ $ $0.00 $ D crown - porcelain /ceramic substrate $ $ $0.00 $

6 includes porcelain jacket crowns, as well as ceramic substrate crowns D crown-porcelain fused to noble metal**(pfm) $ $ $0.00 $ D crown - porcelain fused to predominantly base metal $ $ $0.00 $ D crown- procelain fused to noble metal $ $ $0.00 $ D crown-3/4 cast high noble metal $ $ $0.00 $ D2781 crown-3/4 cast predominantly base metal $ $ $0.00 $ D2782 crown-3/4 cast noble metal $ $ $0.00 $ D2783 crown-3/4 porcelain/ceramic(not a facial veneer) $ $ $0.00 $ D crown-full cast high noble metal $ $ $0.00 $ full veneer crown (FVC or CVC) D crown-full cast predominatly base metal $ $ $0.00 $ full veneer crown (FVC or CVC) D crown - full cast noble metal $ $ $0.00 $ full veneer crown (FVC or CVC) D2799 provisional crown $150/u $150/u $25.00 $ restorative treatment to allow adequate time for healing or completion of other procedures. This includes, but is not limited to, changing vertical dimension, completing periodontal therapy or cracked tooth syndrome. This is not to be used as OTHER RESTORATIVE SERVICES D recement inlay $30.00 $30.00 $30.00 $ D recement crown $30.00 $30.00 $30.00 $ One #1558 bur will be issued for each crown removed D prefabricated stainless steel crown-primary tooth-24 MONTH LIMIT DELTA $75.00 $0.00 $ $ D prefabricated stainless steel crown -permanent tooth $90.00 $ $ $ D prefabricated resin crown $ $ $80.00 $ D prefabricated stainless steel crown with resin window $90.00 $ $ $ D sedative filling - payable if nothing else is done, temporary restoration intended to relieve pain $55.00 $55.00 $50.00 $ if permanent filling done within one year sedative will be deducted from permanent filling payment. not to be used as a base or a liner under restoration D core buildup - including any pins, requires x-ray and narrative, frequently denied as inclusive of crown $80.00 $80.00 $80.00 $ D pin retention-per tooth, in addition to restoration, requires x-ray and narrative $80.00 $80.00 $80.00 $ specify number of pins D cast post and core in addition to crown $ $ $ $ cast post and core is separate from crown D2953 each additional cast post-same tooth $ $ $0.00 $ to be used with D2952 D2954 prefabriacated post and core in addition to crown $ $ $ $ core is built around a prefarbicated post. This procedure includes the core material D2955 post removal (not in conjunction with endodontic therapy) $50.00 $50.00 $0.00 $ for removal of fractured posts(not to be used in conjunction with D3346, D3347, D3348) D2957 each additional prefabricated post -same tooth to be used with 2954 $ $ $0.00 $

7 D2960 labial veneer (resin laminate)-chairside, x-ray required, photos and narrative may slso be necessary $ $ $ $ D2961 labial veneer (resin laminate)-laboratory, x-ray required, photos and narrative may slso be necessary $ $ $ $ D2962 labial veneer (porcelain laminate)-laboratory, x-ray required, photos and narrative may slso be necessary $ $ $ $ D temporary crown, fractured tooth, carrier will deduct from permanent crown $ $ $60.00 $ D crown repair, variable $50.00 $50.00 $0.00 $ includes removal of crown, if necessary. Describe procedure D2999 unspecified restorative procedure, variable variable variable $0.00 $ special components required (other than required abutments) Implant Dentistry variable $0.00 $0.00 for a procedure that is not adequately described by a code. Describe procedure D3000-D3999 IV. ENDODONTICS PULP CAPPING D Pulp cap, direct, exposed pulp, DELTA only for permanent teeth with incomplete root formation $48.00 $50.00 $ $ D Pulp cap,indirect pulp nearly exposed, different date of service from $48.00 $50.00 $ $ PULPOTOMY D Therapeutic pulpotomy(excluding final restoration) $71.00 $90.00 $ $71.00 (Includes the use of formocresol, ferric sulfate, gultadehyde, electric, etc) vital pulpotomy - primary anterior 3 vital pulpotomy - primary molar 3 D3221 pulpal debridement, primary and permanent teeth primary or permanent, for pain relief, not to be used by provider completing the endo Endodontic therapy on primary teeth Endodontic therapy on primary teeth with succedaneous teeth and placement of resorable filling. This includes pulpectomy, cleaning, and fillin of canals with resorable material. D pulpal therapy (resorbable filling) $71.00 $0.00 $0.00 $71.00 anterior, primary tooth/excluding final restoration primary incisors and cuspids D3240 pulpal therapy (resorbable filling)posterior, primary tooth $71.00 $0.00 $0.00 $0.00 Root Canal Therapy (includes treatment plan, clinical procedure and follow-up care) Includes primary teeth without succedaneous teeth and permanent teeth. Complete root canal therapy. Pulpectomy is part of rooth canal therapy. Includes all appointments necessary to complete treatment; also includes intra-operative radiographs. Does not include diagnostic evaluation and necessary radiographs/diagnostic images. D Anterior (excluding final restoration) includes all appointments and radiographs $ $ $ $ D Premolars (excluding final restoration) $ $ $ $ D Molar (excluding final restoration) $ $ $ $ D3331 New code treatment of root canal obstruction; non-surgical access D3332 New code/incomplete endodontic therapy;inoperable or fractured tooth D3333 New code/internal root repair of perforation defects D retreatment of previous root canal therapy-anterior $ $ $0.00 $

8 D retreatment of previous root canal therapy-bicuspid $ $ $0.00 $ D retreatment of previous root canal therapy-molar $ $ $0.00 $ additional biopsy $ $ $0.00 $ culture canal $25.00 $ $0.00 $ D apexification/recalcification-intial visit $ $ $ $ (apical closure/calcific repair of perforations, root resorption, etc.) D apexification/recalcification-interim medication replacement $ $ $0.00 $ D apexification/recalcification -final visit $ $ $0.00 $ APICOECTOMY/PERIRADICULAR SERVICES Surgery to the root surface, i.e. apicoectomy, repair of root perforation, or resorptive defect, curettage of root fracture, removal of extruded filling instruments, root fragment or sealer. Does not include retrograde. D apicoectomy/periradicular surgery-anterior $ $ $ $ D apicoectomy/periradicular surgery-bicuspid(first root) $ $ $ $ D apicoectormy/periadicular surgery-molar(first root) $ $ $ $ D apicoectomy/periradicular surgery (each additonal root) $ $ $0.00 $ More than one root treated during same procedure. D3430 retrograde filling-per root for placement of retrograde filling material during root-report as D3999 and describe $ $ $ $ D3450 root amputation $ $ $0.00 $ for multirooted tooth, crown not sectioned/if crown sectioned use D3920 D3460 endodontic endosseous implant $ $ $0.00 $ D3470 Intentional reimplantation, including necessary splinting for the intentional removal, inspection and treatment of the root and placement of a tooth into its own socket. This does not include necessary retrograde filling material placement. $ $ $0.00 $ bone augmentation material $60.00 $60.00/vial $0.00 $0.00 OTHER ENDODONTIC PROCEDURES D3910 surgical procedure for isolation of tooth with rubber dam $ $ $0.00 $ D3920 hemisection(include root removal/not root canal therapy) $ $ $0.00 $ D3950 canal preparation&fitting of preformed dowel or post $70.00 $70.00 $0.00 $ D3999 unspecified endodontic procedure, variable variable variable $0.00 $ D4000-D4999 V. PERIODONTICS D gingivectomy or gingivoplasty -four or more contiguous teeth or bounded teeth spaces per quadrant $ $ $0.00 $ D gingivectomy or gingivoplasty- - one to three teeth, per quadrant $ $ $0.00 $ D4240 gingival flap procedure, including root planning - four or more contiguous teeth or bounded teeth spaces per quad $ $ $ $ D4241 D4245 gingival flap procedure, including root planning - one to three teeth, per quadrant apically positioned flap $ $ D4249 clinical crown lengthening - hard tissue 1 tooth $ $ $0.00 $

9 (2-3 teeth same quad) 4 or more teeth $ $ $ $0.00 $0.00 $ D osseous surgery (including flap entry & closure) - four or more contiguous teeth or bounded teeth spaces per quad tooth $ $ $0.00 $ quadrant $ $ $0.00 $ D4261 osseous surgery (including flap entry & closure) - one to three teeth, per quadrant D4263 bone replacement graft-first sight in quadrant $0.00 $75.00 $0.00 $0.00 D4264 bone replacement graft-each additional site in quadrant $0.00 $75.00 $0.00 $0.00 performed concurrently w/4264 D4265 biologic materials to aid in soft and osseous tissue regeneration D guided tissue regeneration resorable barrier/per site $ $ $0.00 $0.00 D4267 guided tissue regeneration nonresorable barrier/per site (includes membrane removal) $0.00 $ $0.00 $0.00 D4268 New code/surgical revison procedure, per tooth $ $ $0.00 $0.00 to refine the results of a previously provided surgical procedure $ may require a surgical procedure to modify the irregular contours hard/soft tissues/mucoperiosteal flap may be elevated to access to reshape alveolar bone/flaps replaced or repositioned & sutured D4270 pedicle soft tissue graft procedure 1 tooth $ $ $0.00 $ or more teeth $ $ $0.00 $0.00 D4271 free soft tissue graft, includes donor site, requires fmx, pocket charting, and narrative used with procedure code tooth $ $0.00 $ or more teeth $ $ $0.00 $0.00 D subepithelial connective tissue graft procedures $ $ $0.00 $0.00 requires fmx, most carriers consider this to be cosmetic version d4271 D4274 distal or proximal wedge procedure $ $ $0.00 $0.00 ( when not performed in conjunction with surgical procedures in the same anatomical area) D4275 soft tissue allograft D4276 combined connective tissue and double pedicle graft NON-SURGICAL PERIODONTAL SERVICES Periodontal credit given only if these services are part of periodontal therapy. D4320 provisional splinting-intracoronal $27.00/tooth $27.00/tooth $0.00 $ Delta says variable/usually not covered D4321 provisional splinting-extracoronal $26.00/tooth $26.00/tooth $0.00 $ complete $ $0.00 $25.00 D periodontal scaling and root planing - four or more contiguous teethor bounded teeth spaces per quadrant requires pocket charting/fmx/minimum type II perio Per quadrant (as per treatment plan) $60.00 $75.00 $ Per tooth $25.00 $40.00 $

10 Maximum per mouth $ $ $0.00 $ periodontal reeval $0.00 $ D4342 periodontal scaling and root planing - one to three teeth, per quadrant D full mouth debridement to enable comprehensive evaluation and diagnosis $40.00 $ $0.00 $0.00 and diagnosis, narrative required, can not bill prophy D4381 localized delivery of chemotherapeutic agents $0.00 variable $0.00 $ via a controlled release vehicle into diseased crevicular tissue/by tooth, pocket charting and x-rays required some carriers may say must be done on same as D4341 some on different date from D4341 D periodontal maintenance $50.00 $75.00 $0.00 $ following active treatment, must have history of root plane/surgery pocket charting & narative necessary D4920 unscheduled dressing change(not treating DDS) $30.00 $30.00 $0.00 $ periodontal emergency treatment $55.00 $55.00 $0.00 $ periodontal abscess, acute periodontitis D4999 unspecified periodontal procedure, variable variable variable $0.00 $ COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE) Complete-includes 6 months post placement care. D5000-D5899 V. MAXILLOFACIAL PROSTHETICS D complete denture - maxillary $ $ $750.00$0.00 $ complete denture-maxillary 20 modified tooth form - Levin Blades or Hardy Cutters $ $0.00 $0.00 $ complete maxillary denture - duplicate (within 12 months) $ $0.00 $0.00 $ D complete denture - manbilular $ $ $0.00 $ complete mandibular denture $ $0.00 $0.00 $ modified tooth form -Levin Vlades or Hardy Cutters complete maxillary denture - duplicate within 12 months $ $0.00 $0.00 $ D immediate maxillary denture $ $ $ $0.00 $ complete maxillary denture after recent extractions $ $0.00 $0.00 $ D5140 immediate mandibular denture $ to $ $0.00 $ D Maxillary partial denture - resin base $ to $ $0.00 $ D Mandibular partial denture-resin base $ to $ $0.00 $ D maxillary partial denture- cast metal framework with resin saddles $ to $ $0.00 $ (include clasps, rests & teeth) requires FMX less than 60% Au, Pd or Pt D mandibular partial denture-cast metal framework w/resin $ to $ $0.00 $ saddles (including any conventional clasps, rests and teeth) less than 60% Au, Pd or Pt ADJUSTMENTS TO DENTURES 10

11 D adjust complete denture - maxillary/after 1 year of insertion allowable once every 6 months $25.00 $25.00 $0.00 $ D adjust complete denture - mandibular/dentical-after 1 year of insertion allowable once every 6 months $25.00 $25.00 $0.00 $ D adjust partial denture - maxillary/dentical-after 1 year of instertion allowable once every 6 months $25.00 $25.00 $0.00 $ D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) D adjust partial denture - mandibular $25.00 $25.00 $0.00 $ Repairs to Complete Dentures D repair broken complete denture base $50.00 $50.00 $0.00 $ D replace missing or broken teeth-complete denture (each tooth) $65.00 $65.00 $0.00 $ each additional tooth (dentical maximum 2) $15.00 $20.00 $0.00 $ D repair resin saddle or base $50.00 $50.00 $0.00 $ D repair cast framework(plus lab fee) $75.00 $75.00 $0.00 $ D repair or replace broken clasp(+ lab fee) $75.00 $75.00 $0.00 $ D repair broken tooth $65.00 $65.00 $0.00 $ each addition tooth $15.00 $15.00 $0.00 $ D add tooth to existing partial denture not including clasp or abutment teeth $65.00 $65.00 $0.00 $ each additional tooth $30.00 $30.00 $0.00 $ D add clasp to existing partial denture (+ laboratory fee) $75.00 $75.00 $0.00 $ Each additional clasp $75.00 $75.00 $0.00 $75.00 D5670 replace all teeth and acrylic on cast metal framework (maxillary) D5671 replace all teeth and acrylic on cast metal framework (mandibular) DENTURE REBASE PROCEDURES Rebase - the process of refitting a denture by replacing the base mateiral D rebase complete maxillary denture, adjustments are inclusive for six months $ $ $0.00 $ D rebase complete mandibular denture,adjustments are inclusive for six months $ $ $0.00 $ D rebase maxillary partial denture,adjustments are inclusive for six months $ $ $0.00 $ D rebase mandibular partial denture,adjustments are inclusive for six months $ $ $0.00 $ DENTURE RELINE PROCEDURES Reline - process of resurfacing the tissue side of a denture with new base metal D reline complete maxillary denture (chairside),adjustments are inclusive for 6 months-(delta/other insurance) cal is 12 months $70.00 $ $0.00 $ D reline complete mandibular denture (chairside),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $70.00 $ $0.00 $ D reline maxillary partial denture (chairside),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $70.00 $ $0.00 $ D reline mandibular partial denture (chairside),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $70.00 $ $0.00 $ D reline complete maxillary denture ( laboratory),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $ $ $0.00 $ D reline complete mandibular denture (laboratory),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $ $ $0.00 $ D reline maxillary partial denture ( laboratory),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $ $ $0.00 $ D reline mandibular partial denture (laboratory),adjustments are inclusive for six months-(delta/other insurance) cal is 12 months $ $ $0.00 $ OTHER REMOVABLE PROSTHETIC SERVICES INTERIM PROSTHESIS: a provisional prosthesis designed for use over a limited period of time, 11

12 after which it is to be replaced by a more definitive restoration D5810 interim complete denture (maxillary) - muco adhesion (not covered, if paid will deduct from payment on permanent) $ $ $0.00 $ D5811 interim complete denture (mandibular) - muco adhesion (not covered if paid will deduct from payment on permanent) $ $ $0.00 $ D interim partial denture (maxillary),not covered, if paid will deduct from payment on permanent $ $ $0.00 $ D interim partial denture (mandibular), not covered if paid will deduct from payment on permanent $ $ $0.00 $ (Not 716 CDT) denture remount (occulsal equilibration) D tissue conditioning, maxillary and mandibular dentures, once in 12 months, $50.00 $50.00 $0.00 $ D tissue conditioning,mandibular dentures, once in 12 months, UNDER UTILIZED!!! $50.00 $50.00 $0.00 $ D / 701 overdenture and overpartials, which they will usually cover root canals and filing on. $ $ $0.00 $ many companies will AB, to regualr dentures and partials, some may cover and will usually allow two bilateral abutments, D5861 overdenture - partial, by report $ $ $0.00 $ describe and document procedure as performed D5862 precision attachment, by report $45.00 $ $0.00 $ (Zest anchor or Flexipost) (+ laboratory and attachment fees) D5867 replacement of replaceable part of semi-precision or precision attachment (male or female component) $45.00 $ $0.00 $0.00 D5875 New Code/modification of removable prosthesis following implant surgery $75.00 $0.00 $0.00 D5899 unspecified removable prosthodontic procedure, variable variable variable $0.00 $ D5911 D5912 D5913 D5914 D5915 D5916 D5919 D5922 D5923 D5924 D5925 D5926 D5927 D5928 D5929 D5931 D5932 D5933 D5934 D5935 D5936 D5937 D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS facial moulage (sectional) facial moulage (complete) nasal prosthesis auricular prosthesis orbital prosthesis ocular prosthesis facial prosthesis nasal septal prosthesis ocular prosthesis, interim cranial prosthesis facial augmentation implant prosthesis nasal prosthesis, replacement auricular prosthesis, replacement orbital prosthesis, replacement facial prosthesis, replacement obturator prosthesis, surgical obturator prosthesis, definitive obturator prosthesis, modification mandibular resection prosthesis with guide flange mandibular resection prosthesis without guide flange obturator prosthesis, interim trismus appliance (not for TMD treatment) 12

13 feeding aid speech aid prosthesis, pediatric speech aid prosthesis, adult palatal augmentation prosthesis palatal lift prosthesis, definitive palatal lift prosthesis, interim palatal lift prosthesis, modification D5951 D5952 D5953 D5954 D5955 D5958 D5959 D5960 speech aid prosthesis, modification D surgical stent $45.00 $ $0.00 $ D5983 radiation carrier variable variable $0.00 $ D radiation shield variable variable $0.00 $ D5985 radiation cone locator D5986 fluoride gel carrier, medical for radiation therapy $45.00 $0.00 $0.00 $ D5987 commissure splint $ $ $0.00 $ D5988 surgical splint $45.00 $45.00 $0.00 $ D5999 unspecified maxillofacial prosthesis, variable variable variable $0.00 $ D6000-D6199 VIII. IMPLANT SERVICES D6010 Surgical placement of endosteal implant $ $1, $0.00 $ includes 2nd stage surgery & placement of healing cap D6020 abutment placement or substitution: endosteal implant D6040 Surgical placement of eposteal implant(subperiosteal) framework $1000. $3, $0.00 $ Each additional implant $1000. $ $0.00 $0.00 D6050 Transosseous implant (hospital procedure) $2500. $2, $0.00 $ IMPLANT SUPPORTED PROSTHETICS D6053 implant/abutment supported removable denture for completely edentulous arch D6054 implant/abutment supported removable denture for partially edentulous arch D6055 Implant connecting bar: 2 implants $1, $0.00 $ implants $2, $0.00 $ fixed bar (bone anchored) $3, $0.00 $ D6056 prefabricated abutment $ D6057 custom abutment D6058 abutment supported porcelain/ceramic crown D6059 abutment supported porcelain fused to metal crown (high noble metal) D6060 abutment supported porcelain fused to metal crown (predominantly base metal) D6061 abutment supported porcelain fused to metal crown (noble metal) D6062 abutment supported cast metal crown (high noble metal) D6063 abutment supported cast metal crown (predominantly base metal) 13

14 D6064 D6065 abutment supported cast metal crown (noble metal) implant supported porcelain/ceramic crown D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble $ metal) 12 D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) $ D6068 abutment suported retainer for porcelain/ceramic FPD D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) D6071 abutment supported retainer for porcelain fused to metal FPD D6072 abutment supported retainer for cast metal FPD (high noble metal) D6073 abutment supported retainer for cast metal FPD (predominantly base metal) D6074 abutment supported retainer for cast metal FPD (noble metal) D6075 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) D6078 implant/abutment supported fixed denture for completely edentulous arch D6079 implant/abutment supported fixed denture for partially edentulous arch OTHER IMPLANT SERVICES D6080 Implant maintenance procedures (1st visit free-every visit thereafter is $50.00) $50.00 $ $0.00 $ D6090 Repair implant supported prosthesis, variable variable variable $0.00 $ D6095 Repair implant abutment, variable variable variable $0.00 $ D6100 Implant removal variable variable to $ $0.00 $ D6199 Unspecified implant procedures, variable variable variable $0.00 $ Unspecified implant procedures, variable for Diagnostic Wax UP 2 D6200-D6999 IX. FIXED PROSTHODONTICS BRIDGE PONTICS Fixed bridges are defined by the number of units in the bridge. - a "unit" = each abutment and each pontic - list by using individual crown/pontic codes - non-rigid connectors cost $75.00 per connector - solder connector = $15.00 each - P.D. attachment = $75.00 D6210 Pontic - cast high noble $ $ $0.00 $ D6211 Pontic - cast predominantly base metal $ $ $0.00 $ D6212 Pontic - cast noble metal $ $ $0.00 $ D Pontic - porcelain fused to high noble metal (PFM) $ $ $0.00 $ D6241 Pontic - porcelain fused to predominantly base metal (PFM) $ $ $0.00 $ D6242 Pontic - porcelain fused to noble metal (PFM) $ $ $0.00 $ D6245 New code, all ceramic pontic $ $ $0.00 $ D Pontic - resin with high noble metal $ $0.00 $ D6251 Pontic - resin with predominantly base metal $ $ $0.00 $

15 D6252 Pontic - resin with noble metal $ $0.00 $ D6253 provisional pontic RETAINERS D6545 retainer - cast metal for acid etched fixed prosthesis $ $ $0.00 $0.00 D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis D6600 inlay - porcelain/ceramic, two surfaces D6601 inlay - porcelain/ceramic, three or more surfaces D6602 inlay - cast high noble metal, two surfaces D6603 inlay - cast high noble metal, three or more surfaces D6604 inlay - cast predominantly base metal, two surfaces D6005 inlay - cast predominantly base metal, three or more surfaces D6606 inlay - cast noble metal, two surfaces D6607 inlay - cast noble metal, three or more surfaces D6608 onlay - porcelain/ceramic, two surfaces D6609 onlay - porcelain/ceramic, three or more surfaces D6610 onlay - cast high noble metal, two surfaces D6611 onlay - cast high noble metal, three or more surfaces D6612 onlay - cast predominantly base metal, two surfaces D6613 onlay - cast predominantly base metal, three or more surfaces D6614 onlay - cast noble metal, two surfaces D6615 onlay - cast noble metal, three surfaces Report pontics separately with appropriate code from D6200 series 3 - unit "Maryland Bridge" 8 each additional pontic BRIDGE RETAINERS - CROWNS D6720 Crown - resin with high noble metal** $0.00 $0.00 $ D6721 Crown - resin with predominantly base metal** $ $0.00 $0.00 $ D6722 Crown - resin with noble metal** $ $0.00 $0.00 $ D6740 New code Crown - porcelain/ceramic $ $ $0.00 $ D Crown - porcelain fused to high noble metal**(pfm) $ $ $0.00 $ D6751 Crown - procelain fused to predominantly base metal** (PFM) $ $ $0.00 $ D6752 Crown - porcelain fused to noble metal** (PFM) $ $ $0.00 $ D Crown - 3/4 cast high noble metal** $ $ $0.00 $ D6781 New code Crown - 3/4 predominantly base metal $ $ $0.00 $ D6782 New code Crown - 3/4 cast noble metal $ $ $0.00 $ D6783 New code Crown - 3/4 porcelain/ceramic $ $ $0.00 $ D Full Cast High Nobel Metal $ $ $0.00 $ D6791 Crown - full cast predominantly base metal** $ $ $0.00 $ D6792 Crown - full cast noble metal** $ $ $0.00 $ D6793 provisional retainer crown 15

16 16

17 OTHER FIXED PROSTHETIC SERVICES D6920 connector bar $ $0.00 $0.00 $ D Recement fixed partial denture $50.00 $60.00 $0.00 $ Recement inlay, facing, pontic $35.00 $0.00 $0.00 $ D Stress breaker (+ laboratory fee) $50.00 $ $0.00 $ D6950 Precision attachment (+ laboratory fee) $45.00 $ $0.00 $ report separately from crown; each male and female component constitutes one attachment. Describe type used. D cast post and core in addition to fixed partial denture retainer $ $ $0.00 $ D cast post as part of fixed partial denture retainer $ $0.00 $0.00 $ D Prefabricated post and core $ $ $0.00 $75.00 D6973 core build up for retainer, including any pins $80.00 $80.00 $0.00 $0.00 D6975 Coping - metal $ $ $0.00 $ A thin covering of the coronal portion of crown usually without anatomic conformity. To be used as a definitive restoration. D6976 New code, each additional cast post same tooth, used with D6970 or D6971 $ $ $0.00 $0.00 D6977 New code, each additional prefabricated post (no insurance) used with D6972 $ $ $0.00 $0.00 D Bridge repair, variable $70.00 $ $0.00 $ D6985 pediatric partial denture, fixed D6999 unspecified fixed prosthodontic procedure, by report D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY (INCLUDES LOCAL ANESTHESIA, SUTURING & AND POST-OP CARE D extraction, single tooth $50.00 $65.00 $60.00 $ D root removal-exposed roots $50.00 $65.00 $30.00 $ SURGICAL EXTRACTIONS INCLUDING LOCAL ANESTHESIA AND ROUTINE POST-OP CARE D surgical removal of erupted tooth requiring (including 3rd molars) $90.00 $ $90.00 $ elevation of mucoperiosteal flap and removal of bone and/or section of tooth flap, bone removal, or tooth sectioning, requires narrative Ortho extractions (from advanced students only 0 Single tooth $0.00 $45.00 $60.00 $ teeth $0.00 $ $ $0.00 OTHER SURGICAL PROCEDURES D removal of impacted tooth-soft tissue $ $ $ $ D removal of impacted tooth-partially bony $ $ $ $ D removal of impacted tooth-completely bony $ $ $ $ D removal of impacted tooth-completely bony, $0.00 $ $ $

18 with unusual surgical complications D surgical removal of residual tooth roots (cutting procedure) $0.00 $ $40.00 $ OTHER SURGICAL PROCEDURES D oroantral fistula closure $0.00 $ $0.00 $ D tooth reimplantation and/or stabilization or accidentally evulsed $ $ $ $ or displaced tooth and or alveolus includes splinting and/or stablization tooth implantation $ $ $ $ includes splinting and/or stablization D tooth transplantation (includes reimplantation from $ $ $ $1, one site to another and splinting and or stablization *Dentical procedure limited to children under age 18 splint for stabilization of traumatized tooth $41.00 $41.00 $ $ no re-implantation or transplantation involved D7280 surgical exposure of implacted or unerupted tooth to aid eruption $0.00 $ $ includes ortho attachment, requires film and narrative D surgical exposure of impacted or lunerupted tooth to aid eruption $ $ $35.00 $ D biopsy of oral tissue-hard (bone, tooth $ $ $0.00 $ requires biopsy report D biopsy of oral tissue-soft(all others) $ $ $0.00 $ requires biopsy report D7290 surgical repositioning of teeth $0.00 $150-$250 $0.00 $ D7291 transseptal fiberotomy, by report $0.00 $50.00 $0.00 $ paid under ortho ALVEOLOPLASTY-SURGICAL PREPARATION of Ridge for Dentures D alveoloplasty in conjunction with extractions-per quad $65.00 $90.00 $0.00 $ D alveoloplasty not in conjunction with extractions-per quad $65.00 $ $0.00 $ alveoplasty with extractions-immediate dentures $50.00 $60.00 $0.00 $ VESTIBULOPLASTY D vestibuloplasty-ridge extension (secondary epithelialization $0.00 $ $0.00 $ D7350 vestibuloplasty-ridge extension (including soft tissue grafts, $ $ $0.00 $ muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue without graft $0.00 $ $0.00 $0.00 with graft $0.00 $ $0.00 $ reduction of tuberosity unilateral $0.00 $ $0.00 $ SURGICAL EXCISION OF REACTIVE INFLAMMATORY 18

19 LESIONS (SCAR TISSUE OR LOCALIZED CONGENTIAL LESIONS) D radical excision-lesion diameter up to 1.25cm $ $ $0.00 $ D radical excision-lesion diameter greater than 1.25cm $ $ $0.00 $ REMOVAL OF TUMORS, CYSTS AND NEOPLASMS D excision of benign tumor-lesion diameter up to 1.25cm $ $ $0.00 $ D excision of benign tumor-lesion diameter greater than 1.25 cm $ $ $0.00 $ D7440 excision of malignant tumor - lesion diameter up to 1.25 cm $0.00 $ $0.00 $ D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm $0.00 $ $0.00 $ D removal of odontogenic cyst or tumor-lesion diameter up to 1.25 $ $ $0.00 $ D removal of odontogenic cyst or tumor-lesion greater than 1.25 cm $ $ $0.00 $ D removal of nonodontogenic cyst or tumor-lesion diameter less THAN 1.25 cm $ $ $0.00 $ D removal of nonodontogenic cyst or tumor-lesion deameter greater than 1.25 cm $ $ $0.00 $ Excision of nonodontogenic cyst - marsupialization $0.00 $ $0.00 $ D7465 destruction of lesion(s) by physical or chemical method, by report $0.00 $ $0.00 $ EXCISION OF BONE TISSUE Removal of exostosis including tori - maxilla or mandible - per quadrant D New code removal of exostosis-per site $0.00 $ to 0.5 cm $0.00 $ $0.00 $ to 1 cm $0.00 $ $0.00 $0.00 greater than 1 cm $0.00 $100-$ $0.00 $0.00 D7480 partial ostectomy (guttering or saucerization $0.00 $ $0.00 $ D radical resection of mandible with bone graft $0.00 $ $0.00 $1, SURGICAL INCISION D incision and drainage of abscess-intraoral soft tissue $50.00 $60.00 $0.00 $ film and narrative D incision and drainage of abscess-extraoral soft tissue $75.00 $ $0.00 $ D removal of foreign body, skin, or subcutaneous alveolar tissue $60.00 $75.00 $0.00 $ D removal of reaction-producing foreign bodies,musculosketal system $ $ $0.00 $ D sequestrectomy for osteomyelitis $ $ $0.00 $ D maxillary sinusotomy for removal oftooth fragment of foreign body $ $ $0.00 $ TREATMENT OF FRACTURES-SIMPLE D Maxilla - open reduction $0.00 $1, $0.00 $1, D Maxilla - closed reduction $0.00 $ $0.00 $ D Mandible - open reduction $0.00 $1, $0.00 $1, D Mandible - closed reduction $0.00 $ $0.00 $ D Malar and/or zygomatic arch - open rduction $0.00 $1, $0.00 $ D Malar and /or zgomatic arch -closed reduction $0.00 $ $0.00 $ D7670 Alveolus - open reduction splinting $ $ $0.00 $

20 D7680 Facial bones - complicated reduction $0.00 $1, $0.00 $ TREATMENT OF FRACTURES-COMPOUND D Maxilla - open reduction $0.00 $1, $0.00 $1, D Maxilla - closedreduction $0.00 $ $0.00 $ D Mandible - open reduction $0.00 $1, $0.00 $1, D Mandilbe -closed reduction $0.00 $ $0.00 $ D Malar and/or zygomatic arch - closed reduction $0.00 $1, $0.00 $ D Malar and/or zygomatic arch - closed reduction $0.00 $850 $0.00 $ D7770 Alveolus - open reduction splinting $0.00 $ $0.00 $ D7780 Facial bones - complicated reduction $0.00 $1, $0.00 $ D7810 open reduction of dislocation $0.00 variable $0.00 by report 0 D7820 Treatment of luxation (dislocation)of the mandible (uncomplicated $0.00 $ $0.00 by report 0 D7830 Mandible open reduction $0.00 $1, $0.00 $ D Mandible closed reduction $0.00 variable $0.00 $1, D Malar and/zygomatic arch-open reduction $0.00 variable $0.00 $1, D7880 Occulusal orthotic device, give narrative, bill medical first $ $ $0.00 $ includes one year follow up D7889 Unspecified TMJ therapy, by report $0.00 by report $0.00 $ Injection of temporomandibular joint variable $0.00 $ D7899 Unspecified TMJ therapy, by report $0.00 variable $0.00 $ Trigger point injection $ Spray followed by heat thearpy $75.00 Pain suppressors/tens per 1/2 hour $75.00 Acupuncture - 1/2 hour $75.00 Written reports (first 2 hours); Additional $150 per hour as needed. $ REPAIR OF TRAUMATIC WOUNDS (excludes closure of surgical incisions) D Suture of recent small wounds up to 5cm, wound is about 2" or smaller $35.00 $75.00 $35.00 $ COMPLICATED SUTURING (excludes closure of surgical incisions) D complicated suture-up to 5cm $35.00 $85.00 $35.00 $ D complicated surture -greater than 5cm $0.00 $ $ $ D7920 Skin grafts (identify defect covered, location, and $0.00 $ $0.00 $ type of graft) includes maxillary vestibuloplasty treatment trigeminal neuralgia by injection $0.00 $25.00 $0.00 $ into second and thrid divisions avulsion of trigeminal nerve branch $0.00 $75.00 $0.00 $ D7940 Osteoplasty - for othognathic deformities $0.00 $ $0.00 $ D7941 Osteotomy - mandibular rami $0.00 $ $0.00 $

21 osteotomy - ramus, open $0.00 $ $0.00 $ D7943 osteotomy - mandibular rami with bone graft $0.00 $ $0.00 $ includes obtaining the graft D7955 Repair of maxillofacial soft and hard tissues $0.00 $ $0.00 $ OTHER REPAIR PROCEDURES D Frenulectomy (frenectomy or frenotomy)- separate procedure $ $ $ $ D Excision of hyperplastic tissue - per arch $ $ $ $ D7971 Excision of percoronal gingiva $50.00 $50.00 $ $ D Sialolithotyomy 0 Stone within gland or duct is removed $ $0.00 $ Submaxillary gland and duct $ $0.00 $ Parotid gland and duct $ $0.00 $ D7981 excision of salivary gland, by report $0.00 by report $0.00 $ D7983 closure of salivary fistula $ $ $ $ D7997 appliance removal/not by dentist who placed/includes removal of archwire $75.00 $ $ $0.00 describe procedure Antral sugumentation (sinus lift) $0.00 $ $0.00 $0.00 D8000-D8999 XI. Orthodontics ADVANCED ORTHODONTICS COMPREHENSIVE FULL BANDED ORTHODONTIC TREATMENT MINOR TREATMENT FOR TOOTH GUIDANCE D8010 limited orthodontic treatment of the primary dentition $0.00 variable $0.00 $0.00 D8020 limited orthodontic treatment of the transitional dentition $0.00 variable $0.00 $0.00 D8030 limited orthodontic treatment of the adolescent dentition $0.00 variable $0.00 $0.00 D8040 limited orthodontic treatment of the adult dentition $0.00 variable $0.00 $0.00 INTERCEPTIVE ORTHODONTIC TREATMENT D8050 interceptive orthodontic treatment of the primary dentition $0.00 variable $0.00 $0.00 D8060 interceptive orthodontic treatment of the transitional dentition $0.00 variable $0.00 $0.00 COMPREHENSIVE ORTHODONTIC TREATMENT D8070 comprehensive orthodontic treatment of the transitional dentition $0.00 variable $0.00 $0.00 D8080 comprehensive orthodontic treatment of the adolescent dentition $0.00 variable $0.00 $0.00 D8090 comprehensive orthodontic treatment of the adult dentition $0.00 variable $0.00 $0.00 MINOR TREATMENT FOR TOOTH GUIDANCE D8110 Removable applicance for minor tooth guidance (active) $150-$250 $ $150-$ $ Remake $ $ $ $

22 D8120 Fixed appliance for minor tooth guidance (active) fixed or cemented $ $ $100-$ $ MINOR TREATMENT TO CONTROL HARMFUL HABITS D8210 removable appliance therapy $ $ $ $0.00 Remake $75.00 $75.00 $75.00 $0.00 D8220 fixed appliance therapy to control harmful habits $ $ $125-$ $0.00 Includes appliance for thumb sucking and tongue thrusting Remake $75.00 $75.00 $75.00 $0.00 INTERCEPTIVE ORTHODONTIC TREATMENT D8360 Removable appliance for interceptive orthodontic treatment $ $85.00 $ Remake $75.00 $50.00 $75.00 D8370 Fixed appliance for interceptive orthodontic treatment $ $75.00 $ Remake $75.00 $50.00 $75.00 COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION, SEE CONTRACT B class I malocculsion - permanent dentition, involving extraction class I malocculsion - permanent dentition, involving non-extraction class I malocclusion - permantent dention limited treatment class II maloculusion - permanent dentition, involving extraction class II malocclusion - permanent dentition, involving non-extraction class II malocculusion - permanent dentition, limited treatment class III malocclusion - permanent dentition, involving extraction class III malocclusion - permanent dentition, involving non-extraction class III malocclusion - permanent dentition, limited treatment OTHER ORTHODONTIC SERVICES variable fee variable fee variable fee variable fee variable fee variable fee variable fee variable fee variable fee D8650 treatment of the atypical or extended skeletal case $ variable fee $0.00 D8660 pre-orthodontic treatment visit $0.00 D8670 periodic orthodontic treatment visit (as part of a contract) $0.00 D8680 orthodontic retention (removal of appliances, construction and placement of retainers $0.00 D8690 orthodontic tretment (alternative billing to a contract fee) variable fee $0.00 D8750 Post-treatment stablization (retainer) $ $81.00 $ $0.00 Removable retentive appliance Remake $ $81.00 $ $0.00 Post-treatment stablization $ $81.00 $0.00 $0.00 Fixed or cemented retention appliance Remake $ $81.00 $0.00 $0.00 pediatric retentive appliance, fixed removable $75.00 $55.00 $0.00 $0.00 appliance check $0.00 $0.00 $0.00 $

23 appliance repair $ $0.00 $50.00 $0.00 special appliance $0.00 $0.00 $25.00 $0.00 D8999 unspecified orthrodontic procedure, by report (describe procedure) variable variable variable $0.00 D9000-D9999 XII. Adjunctive General Services UNCLASSIFIED TREATMENT D palliative (emergency) treatment of dental pain-minor procedure $50.00 $50.00 $50.00 $45.00 ANESTHESIA D9210 local anesthesia not in conjunction with operative $0.00 $0.00 $0.00 $0.00 or surgical procedures D9211 regional block anesthesia $0.00 $0.00 $0.00 $0.00 D9212 trigeminal division block anesthesia $0.00 $0.00 $0.00 $0.00 D9215 local anesthesia not in conjunction with operative or surgical procedures $0.00 $0.00 $0.00 $0.00 D deep sedation/general anesthesia-first 30 minutes $0.00 $ $0.00 $0.00 D9221 deep sedation/general anesthesia-each additional 15 minutes $0.00 $25.00 $0.00 $0.00 D analgesia, anxiolysis, inhalation of nitrous oxide $0.00 $0.00 $0.00 $8.00 Nitrous oxide (under 30 minutes) $25.00 $25.00 $25.00 Nitrous oxide (over 30 minutes) $35.00 $35.00 $25.00 D9241 intravenous conscious sedation/ analgesia - first 30 minutes $ $ $ only if medically necessary requires narrative, 3 or more full bony impactions or presence of infection intravenous sedation/analgesia-first 30 minutes intravenous sedation/analgesia-each additional 15 minutes non-intravenous conscious sedation D9242 intravenous conscious sedation/ analgesia - each additional 15 minutes VARIABLE VARIABLE D9248 NEW, NON-INTRAVENOUS SEDATION VARIABLE VARIABLE PROFESSIONAL CONSULTATION D consultation (diagnostic service provided $35.00 $50.00 $35.00 $35.00 by dentist or physician other than practioner providing treatment per 15 minutes $25.00 PROFESSIONAL VISITS D9410 House ls includes nursing homes $50.00 $50.00 $0.00 $0.00 D9420 house/extended care facility call $50.00 $50.00 $0.00 $0.00 D office visit for observation (during regular hours) $35.00 $20.00 $20.00 $20.00 no services performed D office visit - after regularly scheduled hours $35.00 $35.00 $35.00 $

24 D9450 case presentation, detailed and extensive treatment planning DRUGS D threapeutic drug injection, by report Penicillin $6.00 $6.00 $0.00 $0.00 Erythromycin $5.00 $5.00 $0.00 $0.00 Decadron $9.00 $9.00 $0.00 $0.00 Achromycin $6.00 $6.00 $0.00 $0.00 Ancef $20.00 $20.00 $0.00 $0.00 D9630 other drugs and/or medicaments, by report variable variable variable $0.00 MISCELLANEOUS SERVICES D9910 application of densensitizing medicament $11.00 $15.00 $0.00 $0.00 D9911 New Code/application of densensitizing resin for cervical and/or root surface, per tooth $20.00 $20.00 $0.00 $0.00 D9920 behavior management, by report variable variable variable $0.00 D treatment of complications (post-surgical)-unusual circumstances, variable $50.00 variable $50.00 by report D9940 occlusal guard, by report $ $ $ $ D9941 fabrication of athletic mouthguard laboratory constructed $ $ $ $0.00 vacuum formed $30.00 $30.00 $30.00 $0.00 bleaching tray $30.00 $30.00 $30.00 $0.00 D9950 occlusion analysis-mounted case $ $0.00 $0.00 $0.00 includes facebow, interocclusal records, tracings band diagnostic wax-up; for diagnostic casts, see D9951 occlusal adjustment-limited $90.00 $90.00 $0.00 $0.00 D9952 occlusal adjustment-complete $ $ $0.00 $0.00 D9970 enamel microabrasion $0.00 $0.00 $0.00 $0.00 D9971 New code/odontoplasty 1-2 teeth; includes removal of enamel projections $0.00 $0.00 $0.00 $0.00 D9972 New code, external bleaching-per arch, not covered cosmetic $ $ $ $0.00 D9973 New code,external bleaching-per tooth, not covered, cosmetic $50.00 $80.00 $50.00 $0.00 D9974 New code, internal bleaching-per tooth, not covered, cosmetic $50.00 $50.00 $50.00 $0.00 D9999 unspecified adjunctive procedure, by report variable variable variable $