Confidential Fee Schedule Form PDF Details

In today's dental industry, adhering to predetermined fee schedules is an essential aspect of practice management and billing, especially for providers collaborating with insurance networks like Delta Dental. The Confidential Fee Schedule form, as outlined by Delta Dental of Minnesota, serves as a critical document that establishes a clear agreement between healthcare providers and the insurance entity regarding the fees for dental services offered to insured patients. Updated to incorporate CDT 2015 code terminology, this form mandates that dental service providers submit a comprehensive listing of their fees, which must be adhered to when filing claims for services rendered to Delta Dental patients. It also requires providers to declare that the submitted fees represent their standard charges for various procedures, ensuring consistency and transparency in billing practices. Furthermore, the form highlights important procedural requirements, such as the necessity to file fees with Delta Dental 30 days before their effective date and the stipulation that fee revisions cannot be made more frequently than every six months. It encompasses detailed sections for dentist information, including licenses and practice locations, and stresses the inclusion of the MinnesotaCare tax in the filed fees. Also included in the document are exhaustive listings of dental procedures alongside stipulated fees, encompassing diagnostics, preventive, restorative, endodontics, periodontics, prosthetics, maxillofacial prosthetics, and implant services, each detailed with specific codes and anticipated fee structures. This fee schedule not only plays a pivotal role in financial planning for dental practices but also in ensuring that patients covered under Delta Dental plans receive care that is both standardized and accessible.

QuestionAnswer
Form NameConfidential Fee Schedule Form
Form Length9 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 15 sec
Other namesonlay, edentulous, Maxillofacial, minnesota delta fee schedule

Form Preview Example

DELTA DENTAL OF MINNESOTA

P.O. Box 9304

Minneapolis, MN 55440-9304

Confidential Filed Fee Schedule

(Updated to include CDT 2015 code terminology)

Statement of Intent:

Provider File

License # _________________________________

Name ____________________________________

Effective Date: ________________________, 2015

Enter Date: ___________________________, 2015

Operator: _________________________________

Notes: ____________________________________

For Delta Dental Use Only

I agree that each fee submitted to Delta Dental on a claim for dental services I provide to any Delta Dental patient will be these pre-filed fees or the fees actually charged and accepted as payment in full, whichever is less, consistent with the rules and regulations of Delta Dental. If requested by Delta Dental, I will verify by providing documentary evidence satisfactory to Delta Dental that the fees listed on this schedule are my normal (most frequently charged) fees for dental procedures uniformly charged to patients or third party payors. I understand that I cannot revise my pre-filed fees until after the expiration of six (6) months from the effective date indicated below. My fees as pre-filed with Delta Dental on this schedule include the amount of any applicable MinnesotaCare tax.

Note:

Fees must be filed with Delta Dental 30 days prior to their effective date to ensure proper payment of claims. Fee ranges per procedure are not accepted. Please retain a copy of this form with your records.

These new fees are effective on __________________________________________, 2015

Dentist Information: To ensure an accurate update, ALL dentists and ALL locations must be given.

This fee schedule applies to the following dentist(s) at the following locations(s) ONLY. Please attach additional sheets if necessary.

Dentist Personal Signature

Dentist Name (print)

 

Tax Identification

 

License

 

 

NPI Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

Dentist Personal Signature

Dentist Name (print)

 

Tax Identification

 

License

 

 

NPI Number

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

Dentist Personal Signature

Dentist Name (print)

 

Tax Identification

 

License

 

 

NPI Number

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

Dentist Personal Signature

Dentist Name (print)

 

Tax Identification

 

License

 

 

NPI Number

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

 

 

 

State

 

 

Zip

November 2014

Page 1

I. DIAGNOSTIC

D0120

Periodic oral evaluation –

$

 

established patient

 

 

 

 

D0140

Limited oral evaluation –

$

 

problem focused

 

 

 

 

D0145

Oral evaluation for a patient

$

 

under three years of age and

 

 

counseling with primary

 

 

caregiver

 

 

 

 

D0150

Comprehensive oral evaluation –

$

 

new or established patient

 

 

 

 

D0160

Detailed and extensive oral

$

 

evaluation – problem focused, by

 

 

report

 

 

 

 

D0170

Re–evaluation – limited, problem

$

 

focused (established patient; not

 

 

post-operative visit)

 

 

 

 

D0171

Re–evaluation – post-operative

$

 

office visit

 

 

 

 

D0180

Comprehensive periodontal

$

 

evaluation – new or established

 

 

patient

 

 

 

 

D0190

Screening of a patient

$

 

 

 

D0191

Assessment of a patient

$

 

 

 

D0210

Intraoral – complete series of

$

 

radiographic images

 

 

 

 

D0220

Intraoral – periapical first

$

 

radiographic image

 

 

 

 

D0230

Intraoral – periapical each

$

 

additional radiographic image

 

 

 

 

D0240

Intraoral – occlusal radiographic

$

 

image

 

 

 

 

D0250

Extraoral – first radiographic

$

 

image

 

 

 

 

D0260

Extraoral – each additional

$

 

radiographic image

 

 

 

 

D0270

Bitewing – single radiographic

$

 

image

 

 

 

 

D0272

Bitewings – two radiographic

$

 

images

 

 

 

 

D0273

Bitewings – three radiographic

$

 

images

 

 

 

 

D0274

Bitewings – four radiographic

$

 

images

 

 

 

 

D0277

Vertical bitewings – 7 to 8

$

 

radiographic images

 

 

 

 

D0290

Posterior – anterior or lateral

$

 

skull and facial bone survey

 

 

radiographic image

 

 

 

 

D0310

Sialography

$

 

 

 

D0320

Temporomandibular joint

$

 

arthrogram, including injection

 

 

 

 

D0321

Other temporomandibular joint

$

 

radiographic images, by report

 

 

 

 

D0322

Tomographic survey

$

 

 

 

D0330

Panoramic radiographic image

$

 

 

 

D0340

Cephalometric radiographic

$

 

image

 

 

 

 

November 2014

D0350

2D oral/facial photographic

$

 

image obtained intra-orally or

 

 

extra-orally

 

 

 

 

D0351

3D photographic image

$

 

 

 

D0364

Cone beam CT capture and

$

 

interpretation with limited field of

 

 

view – less than one whole jaw

 

 

 

 

D0365

Cone beam CT capture and

$

 

interpretation with field of view

 

 

of one full dental arch –

 

 

mandible

 

 

 

 

D0366

Cone beam CT capture and

$

 

interpretation with field of view

 

 

of one full dental arch – maxilla,

 

 

with or without cranium

 

 

 

 

D0367

Cone beam CT capture and

$

 

interpretation with field of view

 

 

of both jaws; with or without

 

 

cranium

 

 

 

 

D0368

Cone beam CT capture and

$

 

interpretation for TMJ series

 

 

including two or more exposures

 

 

 

 

D0369

Maxillofacial MRI capture and

$

 

interpretation

 

 

 

 

D0370

Maxillofacial ultrasound capture

$

 

and interpretation

 

 

 

 

D0371

Sialoendoscopy capture and

$

 

interpretation

 

 

 

 

D0380

Cone beam CT image capture

$

 

with limited field of view – less

 

 

than one whole jaw

 

 

 

 

D0381

Cone beam CT image capture

$

 

with field of view of one full

 

 

dental arch – mandible

 

 

 

 

D0382

Cone beam CT image capture

$

 

with field of view of one full

 

 

dental arch – maxilla, with or

 

 

without cranium

 

 

 

 

D0383

Cone beam CT image capture

$

 

with field of view of both jaws,

 

 

with or without cranium

 

 

 

 

D0384

Cone beam CT image capture for

$

 

TMJ series including two or more

 

 

exposures

 

 

 

 

D0385

Maxillofacial MRI image capture

$

 

 

 

D0386

Maxillofacial ultrasound image

$

 

capture

 

 

 

 

D0391

Interpretation of diagnostic

$

 

image by a practitioner not

 

 

associated with capture of the

 

 

image, including report

 

 

 

 

D0393

Treatment simulation using 3D

$

 

image volume

 

 

 

 

D0394

Digital subtraction of two or

$

 

more images or image volumes

 

 

of the same modality

 

 

 

 

D0395

Fusion of two or more 3D image

$

 

volumes of one or more

 

 

modalities

 

 

 

 

D0415

Collection of microorganisms for

$

 

culture and sensitivity

 

 

 

 

D0416

Viral culture

$

 

 

 

Page 2

D0417

Collection and preparation of

$

 

saliva sample for laboratory

 

 

diagnostic testing

 

 

 

 

D0418

Analysis of saliva sample

$

 

 

 

D0421

Genetic test for susceptibility to

$

 

oral diseases

 

 

 

 

D0425

Caries susceptibility tests

$

 

 

 

D0431

Adjunctive pre-diagnostic test

$

 

that aids in detection of mucosal

 

 

abnormalities including

 

 

premalignant and malignant

 

 

lesions, not to include cytology

 

 

or biopsy procedures

 

 

 

 

D0460

Pulp vitality tests

$

 

 

 

D0470

Diagnostic casts

$

 

 

 

D0472

Accession of tissue, gross

$

 

examination, preparation and

 

 

transmission of written report

 

 

 

 

D0473

Accession of tissue, gross and

$

 

microscopic examination,

 

 

preparation and transmission of

 

 

written report

 

 

 

 

D0474

Accession of tissue, gross and

$

 

microscopic examination,

 

 

including assessment of surgical

 

 

margins for presence of disease,

 

 

preparation and transmission of

 

 

written report

 

 

 

 

D0475

Decalcification procedure

$

 

 

 

D0476

Special stains for microorganisms

$

 

 

 

D0477

Special stains, not for

$

 

microorganisms

 

 

 

 

D0478

Immunohistochemical stains

$

 

 

 

D0479

Tissue in-situ hybridization,

$

 

including interpretation

 

 

 

 

D0480

Accession of exfoliative cytologic

$

 

smears, microscopic

 

 

examination, preparation and

 

 

transmission of written report

 

 

 

 

D0481

Electron microscopy

$

 

 

 

D0482

Direct immunofluorescence

$

 

 

 

D0483

Indirect immunofluorescence

$

 

 

 

D0484

Consultation on slides prepared

$

 

elsewhere

 

 

 

 

D0485

Consultation, including

$

 

preparation of slides from biopsy

 

 

material supplied by referring

 

 

source

 

 

 

 

D0486

Laboratory accession of

$

 

transepithelial cytologic sample,

 

 

microscopic examination,

 

 

preparation and transmission of

 

 

written report

 

 

 

 

D0502

Other oral pathology procedures,

$

 

by report

 

 

 

 

D0601

Caries risk assessment and

$

 

documentation, with a finding of

 

 

low risk

 

D0602

Caries risk assessment and

$

 

documentation, with a finding of

 

 

moderate risk

 

D0603

Caries risk assessment and

$

 

documentation, with a finding of

 

 

high risk

 

D0999

Unspecified diagnostic

$

 

procedure, by report

 

II. PREVENTIVE

 

 

 

 

D1110

Prophylaxis – adult

$

 

 

 

D1120

Prophylaxis – child

$

 

 

 

D1206

Topical application of fluoride

$

 

varnish

 

 

 

 

D1208

Topical application of fluoride –

$

 

excluding varnish

 

 

 

 

D1310

Nutritional counseling for control

$

 

of dental disease

 

 

 

 

D1320

Tobacco counseling for the

$

 

control and prevention of oral

 

 

disease

 

 

 

 

D1330

Oral hygiene instructions

$

 

 

 

D1351

Sealant – per tooth

$

 

 

 

D1352

Preventive resin restoration in a

$

 

moderate to high caries risk

 

 

patient – permanent tooth

 

 

 

 

D1353

Sealant repair – per tooth

$

 

 

 

D1510

Space maintainer – fixed –

$

 

unilateral

 

 

 

 

D1515

Space maintainer – fixed –

$

 

bilateral

 

 

 

 

D1520

Space maintainer – removable –

$

 

unilateral

 

 

 

 

D1525

Space maintainer – removable –

$

 

bilateral

 

 

 

 

D1550

Re–cement or re–bond space

$

 

maintainer

 

 

 

 

D1555

Removal of fixed space

$

 

maintainer

 

 

 

 

D1999

Unspecified preventive

$

 

procedure, by report

 

 

 

 

III. RESTORATIVE

 

D2140

Amalgam – one surface, primary

$

 

or permanent

 

 

 

 

D2150

Amalgam – two surfaces,

$

 

primary or permanent

 

 

 

 

D2160

Amalgam – three surfaces,

$

 

primary or permanent

 

 

 

 

D2161

Amalgam – four or more

$

 

surfaces, primary or permanent

 

 

 

 

D2330

Resin-based composite – one

$

 

surface, anterior

 

 

 

 

D2331

Resin-based composite – two

$

 

surfaces, anterior

 

 

 

 

D2332

Resin-based composite – three

$

 

surfaces, anterior

 

 

 

 

D2335

Resin-based composite – four or

$

 

more surfaces or involving incisal

 

 

angle (anterior)

 

 

 

 

D2390

Resin-based composite crown,

$

 

anterior

 

 

 

 

D2391

Resin-based composite – one

$

 

surface, posterior

 

 

 

 

D2392

Resin-based composite – two

$

 

surfaces, posterior

 

 

 

 

D2393

Resin-based composite – three

$

 

surfaces, posterior

 

 

 

 

November 2014

D2394

Resin-based composite – four or

$

 

more surfaces, posterior

 

 

 

 

D2410

Gold foil – one surface

$

 

 

 

D2420

Gold foil – two surfaces

$

 

 

 

D2430

Gold foil – three surfaces

$

 

 

 

D2510

Inlay – metallic – one surface

$

 

 

 

D2520

Inlay – metallic – two surfaces

$

 

 

 

D2530

Inlay – metallic – three or more

$

 

surfaces

 

 

 

 

D2542

Onlay – metallic – two surfaces

$

 

 

 

D2543

Onlay – metallic – three surfaces

$

 

 

 

D2544

Onlay – metallic – four or more

$

 

surfaces

 

 

 

 

D2610

Inlay – porcelain/ceramic – one

$

 

surface

 

 

 

 

D2620

Inlay – porcelain/ceramic – two

$

 

surfaces

 

 

 

 

D2630

Inlay – porcelain/ceramic – three

$

 

or more surfaces

 

 

 

 

D2642

Onlay – porcelain/ceramic – two

$

 

surfaces

 

 

 

 

D2643

Onlay – porcelain/ceramic –

$

 

three surfaces

 

 

 

 

D2644

Onlay – porcelain/ceramic – four

$

 

or more surfaces

 

 

 

 

D2650

Inlay – resin-based composite –

$

 

one surface

 

 

 

 

D2651

Inlay – resin-based composite –

$

 

two surfaces

 

 

 

 

D2652

Inlay – resin-based composite –

$

 

three or more surfaces

 

 

 

 

D2662

Onlay – resin-based composite –

$

 

two surfaces

 

 

 

 

D2663

Onlay – resin-based composite –

$

 

three surfaces

 

 

 

 

D2664

Onlay – resin-based composite –

$

 

four or more surfaces

 

 

 

 

D2710

Crown – resin-based composite

$

 

(indirect)

 

 

 

 

D2712

Crown – ¾ resin-based

$

 

composite (indirect)

 

 

 

 

D2720

Crown – resin with high noble

$

 

metal

 

 

 

 

D2721

Crown – resin with

$

 

predominantly base metal

 

 

 

 

D2722

Crown – resin with noble metal

$

 

 

 

D2740

Crown – porcelain/ceramic

$

 

substrate

 

 

 

 

D2750

Crown – porcelain fused to high

$

 

noble metal

 

 

 

 

D2751

Crown – porcelain fused to

$

 

predominantly base metal

 

 

 

 

D2752

Crown – porcelain fused to noble

$

 

metal

 

 

 

 

D2780

Crown – ¾ cast high noble metal

$

 

 

 

D2781

Crown – ¾ cast predominantly

$

 

base metal

 

 

 

 

D2782

Crown – ¾ cast noble metal

$

 

 

 

D2783

Crown – ¾ porcelain/ceramic

$

 

 

 

D2790

Crown – full cast high noble

$

 

metal

 

 

 

 

Page 3

D2791

Crown – full cast predominantly

$

 

base metal

 

 

 

 

D2792

Crown – full cast noble metal

$

 

 

 

D2794

Crown – titanium

$

 

 

 

D2799

Provisional crown – further

$

 

treatment or completion of

 

 

diagnosis necessary prior to final

 

 

impression

 

 

 

 

D2910

Re–cement or re–bond inlay,

$

 

onlay, veneer or partial coverage

 

 

restoration

 

 

 

 

D2915

Re–cement or re–bond indirectly

$

 

fabricated or prefabricated post

 

 

and core

 

 

 

 

D2920

Re–cement or re–bond crown

$

 

 

 

D2921

Reattachment of tooth fragment,

$

 

incisal edge or cusp

 

 

 

 

D2929

Prefabricated porcelain/ceramic

$

 

crown – primary tooth

 

 

 

 

D2930

Prefabricated stainless steel

$

 

crown – primary tooth

 

 

 

 

D2931

Prefabricated stainless steel

$

 

crown – permanent tooth

 

 

 

 

D2932

Prefabricated resin crown

$

 

 

 

D2933

Prefabricated stainless steel

$

 

crown with resin window

 

 

 

 

D2934

Prefabricated esthetic coated

$

 

stainless steel crown – primary

 

 

tooth

 

 

 

 

D2940

Protective restoration

$

 

 

 

D2941

Interim therapeutic restoration –

$

 

primary dentition

 

 

 

 

D2949

Restorative foundation for an

$

 

indirect restoration

 

 

 

 

D2950

Core buildup, including any pins

$

 

when required

 

 

 

 

D2951

Pin retention – per tooth, in

$

 

addition to restoration

 

 

 

 

D2952

Post and core in addition to

$

 

crown, indirectly fabricated

 

 

 

 

D2953

Each additional indirectly

$

 

fabricated post – same tooth

 

 

 

 

D2954

Prefabricated post and core in

$

 

addition to crown

 

 

 

 

D2955

Post removal

$

 

 

 

D2957

Each additional prefabricated

$

 

post – same tooth

 

 

 

 

D2960

Labial veneer (resin laminate) –

$

 

chairside

 

 

 

 

D2961

Labial veneer (resin laminate) –

$

 

laboratory

 

 

 

 

D2962

Labial veneer (porcelain

$

 

laminate) – laboratory

 

 

 

 

D2970

Temporary crown (fractured

$

 

tooth)

 

 

 

 

D2971

Additional procedures to

$

 

construct new crown under

 

 

existing partial denture

 

 

framework

 

 

 

 

D2975

Coping

$

 

 

 

D2980

Crown repair necessitated by

$

 

restorative material failure

 

 

 

 

D2981

Inlay repair necessitated by

$

 

restorative material failure

 

 

 

 

D2982

Onlay repair necessitated by

$

 

restorative material failure

 

 

 

 

D2983

Veneer repair necessitated by

$

 

restorative material failure

 

 

 

 

D2990

Resin infiltration of incipient

$

 

smooth surface lesions

 

 

 

 

D2999

Unspecified restorative

$

 

procedure, by report

 

 

 

 

IV. ENDODONTICS

 

 

 

 

D3110

Pulp cap – direct (excluding final

$

 

restoration)

 

 

 

 

D3120

Pulp cap – indirect (excluding

$

 

final restoration)

 

 

 

 

D3220

Therapeutic pulpotomy

$

 

(excluding final restoration) –

 

 

removal of pulp coronal to the

 

 

dentinocemental junction and

 

 

application of medicament

 

 

 

 

D3221

Pulpal debridement, primary and

$

 

permanent teeth

 

 

 

 

D3222

Partial pulpotomy for

$

 

apexogenesis – permanent tooth

 

 

with incomplete root

 

 

development

 

 

 

 

D3230

Pulpal therapy (resorbable filling)

$

 

– anterior, primary tooth

 

 

(excluding final restoration)

 

 

 

 

D3240

Pulpal therapy (resorbable filling)

$

 

– posterior, primary tooth

 

 

(excluding final restoration)

 

 

 

 

D3310

Endodontic therapy, anterior

$

 

tooth (excluding final

 

 

restoration)

 

 

 

 

D3320

Endodontic therapy, bicuspid

$

 

tooth (excluding final

 

 

restoration)

 

 

 

 

D3330

Endodontic therapy, molar

$

 

(excluding final restoration)

 

 

 

 

D3331

Treatment of root canal

$

 

obstruction; non-surgical access

 

 

 

 

D3332

Incomplete endodontic therapy;

$

 

inoperable, unrestorable or

 

 

fractured tooth

 

 

 

 

D3333

Internal root repair of perforation

$

 

defects

 

 

 

 

D3346

Retreatment of previous root

$

 

canal therapy – anterior

 

 

 

 

D3347

Retreatment of previous root

$

 

canal therapy – bicuspid

 

 

 

 

D3348

Retreatment of previous root

$

 

canal therapy – molar

 

 

 

 

D3351

Apexification/recalcification –

$

 

initial visit (apical closure/calcific

 

 

repair of perforations, root

 

 

resorption, etc.)

 

 

 

 

D3352

Apexification/recalcification –

$

 

interim medication replacement

 

 

 

 

D3353

Apexification/recalcification –

$

 

final visit (includes completed

 

 

root canal therapy – apical

 

 

closure/calcific repair of

 

 

perforations, root resorption,

 

 

etc.)

 

 

 

 

D3355

Pulpal regeneration – initial visit

$

 

 

 

D3356

Pulpal regeneration – interim

$

 

medication replacement

 

 

 

 

November 2014

 

D3357

Pulpal regeneration – completion

$

 

 

of treatment

 

 

 

 

 

 

D3410

Apicoectomy – anterior

$

 

 

 

 

 

D3421

Apicoectomy – bicuspid (first

$

 

 

root)

 

 

 

 

 

 

D3425

Apicoectomy – molar (first root)

$

 

 

 

 

 

D3426

Apicoectomy (each additional

$

 

 

root)

 

 

 

 

 

 

D3427

Periradicular surgery without

$

 

 

apicoectomy

 

 

 

 

 

 

D3428

Bone graft in conjunction with

$

 

 

periradicular surgery – per tooth,

 

 

 

single site

 

 

 

 

 

 

D3429

Bone graft in conjunction with

$

 

 

periradicular surgery – each

 

 

 

additional contiguous tooth in

 

 

 

the same surgical site

 

 

 

 

 

 

D3430

Retrograde filling – per root

$

 

 

 

 

 

D3431

Biologic materials to aid in soft

$

 

 

and osseous tissue regeneration

 

 

 

in conjunction with periradicular

 

 

 

surgery

 

 

 

 

 

 

D3432

Guided tissue regeneration,

$

 

 

resorbable barrier, per site, in

 

 

 

conjunction with periradicular

 

 

 

surgery

 

 

 

 

 

 

D3450

Root amputation – per root

$

 

 

 

 

 

D3460

Endodontic endosseous implant

$

 

 

 

 

 

D3470

Intentional re-implantation

$

 

 

(including necessary splinting)

 

 

 

 

 

 

D3910

Surgical procedure for isolation

$

 

 

of tooth with rubber dam

 

 

 

 

 

 

D3920

Hemisection (including any root

$

 

 

removal), not including root

 

 

 

canal therapy

 

 

 

 

 

 

D3950

Canal preparation and fitting of

$

 

 

preformed dowel or post

 

 

 

 

 

 

D3999

Unspecified endodontic

$

 

 

procedure, by report

 

 

 

 

 

 

V. PERIODONTICS

 

 

 

 

 

 

D4210

Gingivectomy or gingivoplasty -

$

 

 

four or more contiguous teeth or

 

 

 

tooth bounded spaces per

 

 

 

quadrant

 

 

 

 

 

 

D4211

Gingivectomy or gingivoplasty –

$

 

 

one to three contiguous teeth or

 

 

 

tooth bounded spaces per

 

 

 

quadrant

 

 

 

 

 

 

D4212

Gingivectomy or gingivoplasty to

$

 

 

allow access for restorative

 

 

 

procedure, per tooth

 

 

 

 

 

 

D4230

Anatomical crown exposure –

$

 

 

four or more contiguous teeth

 

 

 

per quadrant

 

 

 

 

 

 

D4231

Anatomical crown exposure –

$

 

 

one to three teeth per quadrant

 

 

 

 

 

 

D4240

Gingival flap procedure, including

$

 

 

root planing – four or more

 

 

 

contiguous teeth or tooth

 

 

 

bounded spaces per quadrant

 

 

 

 

 

 

D4241

Gingival flap procedure, including

$

 

 

root planing – one to three

 

 

 

contiguous teeth or tooth

 

 

 

bounded spaces per quadrant

 

 

 

 

 

 

D4245

Apically positioned flap

$

 

 

 

 

Page 4

D4249

Clinical crown lengthening – hard

$

 

tissue

 

 

 

 

D4260

Osseous surgery (including

$

 

elevation of a full thickness flap

 

 

and closure) – four or more

 

 

contiguous teeth or tooth

 

 

bounded spaces per quadrant

 

 

 

 

D4261

Osseous surgery (including

$

 

elevation of a full thickness flap

 

 

and closure) – one to three

 

 

contiguous teeth or tooth

 

 

bounded spaces per quadrant

 

 

 

 

D4263

Bone replacement graft – first

$

 

site in quadrant

 

 

 

 

D4264

Bone replacement graft – each

$

 

additional site in quadrant

 

 

 

 

D4265

Biologic materials to aid in soft

$

 

and osseous tissue regeneration

 

 

 

 

D4266

Guided tissue regeneration –

$

 

resorbable barrier, per site

 

 

 

 

D4267

Guided tissue regeneration –

$

 

non-resorbable barrier, per site

 

 

(includes membrane removal)

 

 

 

 

D4268

Surgical revision procedure, per

$

 

tooth

 

 

 

 

D4270

Pedicle soft tissue graft

$

 

procedure

 

 

 

 

D4273

Subepithelial connective tissue

$

 

graft procedures, per tooth

 

 

 

 

D4274

Distal or proximal wedge

$

 

procedure (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, per tooth

 

 

 

 

D4277

Free soft tissue graft procedure

$

 

(including donor site surgery),

 

 

first tooth or edentulous tooth

 

 

position in graft

 

 

 

 

D4278

Free soft tissue graft procedure

$

 

(including donor site surgery),

 

 

each additional contiguous tooth

 

 

or edentulous tooth position in

 

 

same graft site

 

 

 

 

D4320

Provisional splinting –

$

 

intracoronal

 

 

 

 

D4321

Provisional splinting –

$

 

extracoronal

 

 

 

 

D4341

Periodontal scaling and root

$

 

planing – four or more teeth per

 

 

quadrant

 

 

 

 

D4342

Periodontal scaling and root

$

 

planing – one to three teeth per

 

 

quadrant

 

 

 

 

D4355

Full mouth debridement to

$

 

enable comprehensive evaluation

 

 

and diagnosis

 

 

 

 

D4381

Localized delivery of

$

 

antimicrobial agents via a

 

 

controlled release vehicle into

 

 

diseased crevicular tissue, per

 

 

tooth

 

 

 

 

D4910

Periodontal maintenance

$

 

 

 

D4920

Unscheduled dressing change

$

 

(by someone other than treating

 

 

dentist or their staff)

 

 

 

 

D4921

Gingival irrigation – per quadrant

$

 

 

 

D4999

Unspecified periodontal

$

 

procedure, by report

 

 

 

 

VI. PROSTHODONTICS (REMOVABLE)

 

 

 

 

D5110

Complete denture – maxillary

$

 

 

 

D5120

Complete denture – mandibular

$

 

 

 

D5130

Immediate denture – maxillary

$

 

 

 

D5140

Immediate denture – mandibular

$

 

 

 

D5211

Maxillary partial denture – resin

$

 

base (including any conventional

 

 

clasps, rests and teeth)

 

 

 

 

D5212

Mandibular partial denture –

$

 

resin base (including any

 

 

conventional clasps, rests and

 

 

teeth)

 

 

 

 

D5213

Maxillary partial denture – cast

$

 

metal framework with resin

 

 

denture bases (including any

 

 

conventional clasps, rests and

 

 

teeth)

 

 

 

 

D5214

Mandibular partial denture – cast

$

 

metal framework with resin

 

 

denture bases (including any

 

 

conventional clasps, rests and

 

 

teeth)

 

 

 

 

D5225

Maxillary partial denture –

$

 

flexible base (including any

 

 

clasps, rests and teeth)

 

 

 

 

D5226

Mandibular partial denture –

$

 

flexible base (including any

 

 

clasps, rests and teeth)

 

 

 

 

D5281

Removable unilateral partial

$

 

denture – one piece cast metal

 

 

(including clasps and teeth)

 

 

 

 

D5410

Adjust complete denture –

$

 

maxillary

 

 

 

 

D5411

Adjust complete denture –

$

 

mandibular

 

 

 

 

D5421

Adjust partial denture – maxillary

$

 

 

 

D5422

Adjust partial denture –

$

 

mandibular

 

 

 

 

D5510

Repair broken complete denture

$

 

base

 

 

 

 

D5520

Replace missing or broken teeth

$

 

– complete denture (each tooth)

 

 

 

 

D5610

Repair resin denture base

$

 

 

 

D5620

Repair cast framework

$

 

 

 

D5630

Repair or replace broken clasp

$

 

 

 

D5640

Replace broken teeth – per tooth

$

 

 

 

D5650

Add tooth to existing partial

$

 

denture

 

 

 

 

D5660

Add clasp to existing partial

$

 

denture

 

 

 

 

D5670

Replace all teeth and acrylic on

$

 

cast metal framework (maxillary)

 

 

 

 

D5671

Replace all teeth and acrylic on

$

 

cast metal framework

 

 

(mandibular)

 

 

 

 

D5710

Rebase complete maxillary

$

 

denture

 

 

 

 

D5711

Rebase complete mandibular

$

 

denture

 

 

 

 

D5720

Rebase maxillary partial denture

$

 

 

 

November 2014

 

D5721

Rebase mandibular partial

$

 

 

denture

 

 

 

 

 

 

D5730

Reline complete maxillary

$

 

 

denture (chairside)

 

 

 

 

 

 

D5731

Reline complete mandibular

$

 

 

denture (chairside)

 

 

 

 

 

 

D5740

Reline maxillary partial denture

$

 

 

(chairside)

 

 

 

 

 

 

D5741

Reline mandibular partial denture

$

 

 

(chairside)

 

 

 

 

 

 

D5750

Reline complete maxillary

$

 

 

denture (laboratory)

 

 

 

 

 

 

D5751

Reline complete mandibular

$

 

 

denture (laboratory)

 

 

 

 

 

 

D5760

Reline maxillary partial denture

$

 

 

(laboratory)

 

 

 

 

 

 

D5761

Reline mandibular partial denture

$

 

 

(laboratory)

 

 

 

 

 

 

D5810

Interim complete denture

$

 

 

(maxillary)

 

 

 

 

 

 

D5811

Interim complete denture

$

 

 

(mandibular)

 

 

 

 

 

 

D5820

Interim partial denture

$

 

 

(maxillary)

 

 

 

 

 

 

D5821

Interim partial denture

$

 

 

(mandibular)

 

 

 

 

 

 

D5850

Tissue conditioning, maxillary

$

 

 

 

 

 

D5851

Tissue conditioning, mandibular

$

 

 

 

 

 

D5862

Precision attachment, by report

$

 

 

 

 

 

D5863

Overdenture – complete

$

 

 

maxillary

 

 

 

 

 

 

D5864

Overdenture – partial maxillary

$

 

 

 

 

 

D5865

Overdenture – complete

$

 

 

mandibular

 

 

 

 

 

 

D5866

Overdenture – partial mandibular

$

 

 

 

 

 

D5867

Replacement of replaceable part

$

 

 

of semi-precision or precision

 

 

 

attachment (male or female

 

 

 

component)

 

 

 

 

 

 

D5875

Modification of removable

$

 

 

prosthesis following implant

 

 

 

surgery

 

 

 

 

 

 

D5899

Unspecified removable

$

 

 

prosthodontic procedure, by

 

 

 

report

 

 

 

 

 

 

VII. MAXILLOFACIAL PROSTHETICS

 

 

 

 

 

 

D5911

Facial moulage (sectional)

$

 

 

 

 

 

D5912

Facial moulage (complete)

$

 

 

 

 

 

D5913

Nasal prosthesis

$

 

 

 

 

 

D5914

Auricular prosthesis

$

 

 

 

 

 

D5915

Orbital prosthesis

$

 

 

 

 

 

D5916

Ocular prosthesis

$

 

 

 

 

 

D5919

Facial prosthesis

$

 

 

 

 

 

D5922

Nasal septal prosthesis

$

 

 

 

 

 

D5923

Ocular prosthesis, interim

$

 

 

 

 

 

D5924

Cranial prosthesis

$

 

 

 

 

 

D5925

Facial augmentation implant

$

 

 

prosthesis

 

 

 

 

 

 

D5926

Nasal prosthesis, replacement

$

 

 

 

 

 

D5927

Auricular prosthesis, replacement

$

 

 

 

 

Page 5

D5928

Orbital prosthesis, replacement

$

 

 

 

D5929

Facial prosthesis, replacement

$

 

 

 

D5931

Obturator prosthesis, surgical

$

 

 

 

D5932

Obturator prosthesis, definitive

$

 

 

 

D5933

Obturator prosthesis,

$

 

modification

 

 

 

 

D5934

Mandibular resection prosthesis

$

 

with guide flange

 

 

 

 

D5935

Mandibular resection prosthesis

$

 

without guide flange

 

 

 

 

D5936

Obturator prosthesis, interim

$

 

 

 

D5937

Trismus appliance (not for TMD

$

 

treatment)

 

 

 

 

D5951

Feeding aid

$

 

 

 

D5952

Speech aid prosthesis, pediatric

$

 

 

 

D5953

Speech aid prosthesis, adult

$

 

 

 

D5954

Palatal augmentation prosthesis

$

 

 

 

D5955

Palatal lift prosthesis, definitive

$

 

 

 

D5958

Palatal lift prosthesis, interim

$

 

 

 

D5959

Palatal lift prosthesis,

$

 

modification

 

 

 

 

D5960

Speech aid prosthesis,

$

 

modification

 

 

 

 

D5982

Surgical stent

$

 

 

 

D5983

Radiation carrier

$

 

 

 

D5984

Radiation shield

$

 

 

 

D5985

Radiation cone locator

$

 

 

 

D5986

Fluoride gel carrier

$

 

 

 

D5987

Commissure splint

$

 

 

 

D5988

Surgical splint

$

 

 

 

D5991

Vesiculobullous disease

$

 

medicament carrier

 

 

 

 

D5992

Adjust maxillofacial prosthetic

$

 

appliance, by report

 

 

 

 

D5993

Maintenance and cleaning of a

$

 

maxillofacial prosthesis (extra- or

 

 

intra-oral) other than required

 

 

adjustments, by report

 

 

 

 

D5994

Periodontal medicament carrier

$

 

with peripheral seal – laboratory

 

 

processed

 

 

 

 

D5999

Unspecified maxillofacial

$

 

prosthesis, by report

 

 

 

 

VIII. IMPLANT SERVICES

 

 

 

 

D6010

Surgical placement of implant

$

 

body: endosteal implant

 

 

 

 

D6011

Second stage implant surgery

$

 

 

 

D6012

Surgical placement of interim

$

 

implant body for transitional

 

 

prosthesis: endosteal implant

 

 

 

 

D6013

Surgical placement of mini

$

 

implant

 

 

 

 

D6040

Surgical placement: eposteal

$

 

implant

 

 

 

 

D6050

Surgical placement: transosteal

$

 

implant

 

 

 

 

D6051

Interim abutment

$

 

 

 

D6052

Semi – precision attachment

$

 

abutment

 

 

 

 

D6055

Connecting bar – implant

$

 

supported or abutment

 

 

supported

 

 

 

 

D6056

Prefabricated abutment –

$

 

includes modification and

 

 

placement

 

 

 

 

D6057

Custom fabricated abutment –

$

 

includes placement

 

 

 

 

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)

 

 

 

 

D6064

Abutment supported cast metal

$

 

crown (noble metal)

 

 

 

 

D6065

Implant supported

$

 

porcelain/ceramic crown

 

 

 

 

D6066

Implant supported porcelain

$

 

fused to metal crown (titanium,

 

 

titanium alloy, high noble metal)

 

 

 

 

D6067

Implant supported metal crown

$

 

(titanium, titanium alloy, high

 

 

noble metal)

 

 

 

 

D6068

Abutment supported 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

 

 

(noble metal)

 

 

 

 

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

$

 

ceramic FPD

 

 

 

 

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)

 

 

 

 

D6080

Implant maintenance procedures

$

 

when prostheses are removed

 

 

and reinserted, including

 

 

cleansing of prosthesis and

 

 

abutments

 

 

 

 

November 2014

D6090

Repair implant supported

$

 

prosthesis, by report

 

 

 

 

D6091

Replacement of semi-precision or

$

 

precision attachment (male or

 

 

female component) of

 

 

implant/abutment supported

 

 

prosthesis, per attachment

 

 

 

 

D6092

Re–cement or re–bond

$

 

implant/abutment supported

 

 

crown

 

 

 

 

D6093

Re–cement or re–bond/implant

$

 

abutment supported fixed partial

 

 

denture

 

 

 

 

D6094

Abutment supported crown

$

 

(titanium)

 

 

 

 

D6095

Repair implant abutment, by

$

 

report

 

 

 

 

D6100

Implant removal, by report

$

 

 

 

D6101

Debridement of a peri–implant

$

 

defect or defects surrounding a

 

 

single implant, and surface

 

 

cleaning of the exposed implant

 

 

surfaces, including flap entry and

 

 

closure

 

 

 

 

D6102

Debridement and osseous

$

 

contouring of a peri–implant

 

 

defect or defects surrounding a

 

 

single implant and includes

 

 

surface cleaning of the exposed

 

 

implant surfaces, including flap

 

 

entry and closure

 

 

 

 

D6103

Bone graft for repair of peri–

$

 

implant defect – does not include

 

 

flap entry and closure. Placement

 

 

of a barrier membrane or

 

 

biologic materials to aid in

 

 

osseous regeneration are

 

 

reported separately

 

 

 

 

D6104

Bone graft at time of implant

$

 

placement

 

 

 

 

D6110

Implant/abutment supported

$

 

removable denture for

 

 

edentulous arch – maxillary

 

 

 

 

D6111

Implant/abutment supported

$

 

removable denture for

 

 

edentulous arch – mandibular

 

 

 

 

D6112

Implant/abutment supported

$

 

removable denture for partially

 

 

edentulous arch – maxillary

 

 

 

 

D6113

Implant/abutment supported

$

 

removable denture for partially

 

 

edentulous arch – mandibular

 

 

 

 

D6114

Implant/abutment supported

$

 

fixed denture for edentulous arch

 

 

– maxillary

 

 

 

 

D6115

Implant/abutment supported

$

 

fixed denture for edentulous arch

 

 

– mandibular

 

 

 

 

D6116

Implant/abutment supported

$

 

fixed denture for partially

 

 

edentulous arch – maxillary

 

 

 

 

D6117

Implant/abutment supported

$

 

fixed denture for partially

 

 

edentulous arch – mandibular

 

 

 

 

D6190

Radiographic/surgical implant

$

 

index, by report

 

 

 

 

D6194

Abutment supported retainer

$

 

crown for FPD (titanium)

 

 

 

 

Page 6

 

D6199

Unspecified implant procedure,

$

 

 

by report

 

 

 

 

 

 

IX. PROSTHODONTICS, FIXED

 

 

 

 

 

 

D6205

Pontic – indirect resin based

$

 

 

composite

 

 

 

 

 

 

D6210

Pontic – cast high noble metal

$

 

 

 

 

 

D6211

Pontic – cast predominantly base

$

 

 

metal

 

 

 

 

 

 

D6212

Pontic – cast noble metal

$

 

 

 

 

 

D6214

Pontic – titanium

$

 

 

 

 

 

D6240

Pontic – porcelain fused to high

$

 

 

noble metal

 

 

 

 

 

 

D6241

Pontic – porcelain fused to

$

 

 

predominantly base metal

 

 

 

 

 

 

D6242

Pontic – porcelain fused to noble

$

 

 

metal

 

 

 

 

 

 

D6245

Pontic – porcelain/ceramic

$

 

 

 

 

 

D6250

Pontic – resin with high noble

$

 

 

metal

 

 

 

 

 

 

D6251

Pontic – resin with predominantly

$

 

 

base metal

 

 

 

 

 

 

D6252

Pontic – resin with noble metal

$

 

 

 

 

 

D6253

Provisional pontic – further

$

 

 

treatment or completion of

 

 

 

diagnosis necessary prior to final

 

 

 

impression

 

 

 

 

 

 

D6545

Retainer – cast metal for resin

$

 

 

bonded fixed prosthesis

 

 

 

 

 

 

D6548

Retainer – porcelain/ceramic for

$

 

 

resin bonded fixed prosthesis

 

 

 

 

 

 

D6549

Resin retainer – 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

 

 

 

 

 

 

D6605

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

$

 

or more surfaces

 

 

 

 

D6624

Inlay – titanium

$

 

 

 

D6634

Onlay – titanium

$

 

 

 

D6710

Crown – indirect resin based

$

 

composite

 

 

 

 

D6720

Crown – resin with high noble

$

 

metal

 

 

 

 

D6721

Crown – resin with

$

 

predominantly base metal

 

 

 

 

D6722

Crown – resin with noble metal

$

 

 

 

D6740

Crown – porcelain/ceramic

$

 

 

 

D6750

Crown – porcelain fused to high

$

 

noble metal

 

 

 

 

D6751

Crown – porcelain fused to

$

 

predominantly base metal

 

 

 

 

D6752

Crown – porcelain fused to noble

$

 

metal

 

 

 

 

D6780

Crown – ¾ cast high noble metal

$

 

 

 

D6781

Crown – ¾ cast predominantly

$

 

base metal

 

 

 

 

D6782

Crown – ¾ cast noble metal

$

 

 

 

D6783

Crown – ¾ porcelain/ceramic

$

 

 

 

D6790

Crown – full cast high noble

$

 

metal

 

 

 

 

D6791

Crown – full cast predominantly

$

 

base metal

 

 

 

 

D6792

Crown – full cast noble metal

$

 

 

 

D6793

Provisional retainer crown –

$

 

further treatment or completion

 

 

of diagnosis necessary prior to

 

 

final impression

 

 

 

 

D6794

Crown – titanium

$

 

 

 

D6920

Connector bar

$

 

 

 

D6930

Re–cement or re–bond fixed

$

 

partial denture

 

 

 

 

D6940

Stress breaker

$

 

 

 

D6950

Precision attachment

$

 

 

 

D6980

Fixed partial denture repair

$

 

necessitated by restorative

 

 

material failure

 

 

 

 

D6985

Pediatric partial denture, fixed

$

 

 

 

D6999

Unspecified fixed prosthodontic

$

 

procedure, by report

 

 

 

 

X. ORAL & MAXILLOFACIAL SURGERY

 

 

 

 

D7111

Extraction, coronal remnants –

$

 

deciduous tooth

 

 

 

 

D7140

Extraction, erupted tooth or

$

 

exposed root (elevation and/or

 

 

forceps removal)

 

 

 

 

D7210

Surgical removal of erupted

$

 

tooth requiring removal of bone

 

 

and/or sectioning of tooth, and

 

 

including elevation of

 

 

mucoperiosteal flap if indicated

 

 

 

 

D7220

Removal of impacted tooth – soft

$

 

tissue

 

 

 

 

D7230

Removal of impacted tooth –

$

 

partially bony

 

 

 

 

D7240

Removal of impacted tooth –

$

 

completely bony

 

 

 

 

November 2014

D7241

Removal of impacted tooth –

$

 

completely bony, with unusual

 

 

surgical complications

 

 

 

 

D7250

Surgical removal of residual

$

 

tooth roots (cutting procedure)

 

 

 

 

D7251

Coronectomy – intentional partial

$

 

tooth removal

 

 

 

 

D7260

Oroantral fistula closure

$

 

 

 

D7261

Primary closure of a sinus

$

 

perforation

 

 

 

 

D7270

Tooth re–implantation and/or

$

 

stabilization of accidentally

 

 

evulsed or displaced tooth

 

 

 

 

D7272

Tooth transplantation (includes

$

 

re–implantation from one site to

 

 

another and splinting and/or

 

 

stabilization)

 

 

 

 

D7280

Surgical access of an unerupted

$

 

tooth

 

 

 

 

D7282

Mobilization of erupted or

$

 

malpositioned tooth to aid

 

 

eruption

 

 

 

 

D7283

Placement of device to facilitate

$

 

eruption of impacted tooth

 

 

 

 

D7285

Incisional biopsy of oral tissue –

$

 

hard (bone, tooth)

 

 

 

 

D7286

Incisional biopsy of oral tissue –

$

 

soft

 

 

 

 

D7287

Exfoliative cytological sample

$

 

collection

 

 

 

 

D7288

Brush biopsy – transepithelial

$

 

sample collection

 

 

 

 

D7290

Surgical repositioning of teeth

$

 

 

 

D7291

Transseptal fiberotomy/supra

$

 

crestal fiberotomy, by report

 

 

 

 

D7292

Surgical placement of temporary

$

 

anchorage device [screw

 

 

retained plate] requiring flap;

 

 

includes device removal

 

 

 

 

D7293

Surgical placement of temporary

$

 

anchorage device requiring flap;

 

 

includes device removal

 

 

 

 

D7294

Surgical placement of temporary

$

 

anchorage device without flap;

 

 

includes device removal

 

 

 

 

D7295

Harvest of bone for use in

$

 

autogenous grafting procedure

 

 

 

 

D7310

Alveoloplasty in conjunction with

$

 

extractions – four or more teeth

 

 

or tooth spaces, per quadrant

 

 

 

 

D7311

Alveoloplasty in conjunction with

$

 

extractions – one to three teeth

 

 

or tooth spaces, per quadrant

 

 

 

 

D7320

Alveoloplasty not in conjunction

$

 

 

with extractions – four or more

 

 

teeth or tooth spaces, per

 

 

quadrant

 

 

 

 

D7321

Alveoloplasty not in conjunction

$

 

 

with extractions – one to three

 

 

teeth or tooth spaces, per

 

 

quadrant

 

 

 

 

D7340

Vestibuloplasty – ridge extension

$

 

(secondary epithelialization)

 

 

 

 

Page 7

D7350

Vestibuloplasty – ridge extension

$

 

(including soft tissue grafts,

 

 

muscle reattachment, revision of

 

 

soft tissue attachment and

 

 

management of hypertrophied

 

 

and hyperplastic tissue)

 

 

 

 

D7410

Excision of benign lesion up to

$

 

 

1.25 cm

 

 

 

 

D7411

Excision of benign lesion greater

$

 

than 1.25 cm

 

 

 

 

D7412

Excision of benign lesion,

$

 

 

complicated

 

 

 

 

D7413

Excision of malignant lesion up

$

 

 

to 1.25 cm

 

 

 

 

D7414

Excision of malignant lesion

$

 

 

greater than 1.25 cm

 

 

 

 

D7415

Excision of malignant lesion,

$

 

 

complicated

 

 

 

 

D7440

Excision of malignant tumor –

$

 

 

lesion diameter up to 1.25 cm

 

 

 

 

D7441

Excision of malignant tumor –

$

 

 

lesion diameter greater than 1.25

 

 

cm

 

 

 

 

D7450

Removal of benign odontogenic

$

 

 

cyst or tumor – lesion diameter

 

 

up to 1.25 cm

 

 

 

 

D7451

Removal of benign odontogenic

$

 

 

cyst or tumor – lesion diameter

 

 

greater than 1.25 cm

 

 

 

 

D7460

Removal of benign

$

 

 

nonodontogenic cyst or tumor –

 

 

lesion diameter up to 1.25 cm

 

 

 

 

D7461

Removal of benign

$

 

 

nonodontogenic cyst or tumor –

 

 

lesion diameter greater than 1.25

 

 

cm

 

 

 

 

D7465

Destruction of lesion(s) by

$

 

 

physical or chemical method, by

 

 

report

 

 

 

 

D7471

Removal of lateral exostosis

$

 

 

(maxilla or mandible)

 

 

 

 

D7472

Removal of torus palatinus

$

 

 

 

 

D7473

Removal of torus mandibularis

$

 

 

 

 

D7485

Surgical reduction of osseous

$

 

 

tuberosity

 

 

 

 

D7490

Radical resection of maxilla or

$

 

 

mandible

 

 

 

 

D7510

Incision and drainage of abscess

$

 

– intraoral soft tissue

 

 

 

 

D7511

Incision and drainage of abscess

$

 

– intraoral soft tissue -

 

 

complicated (includes drainage

 

 

of multiple fascial spaces)

 

 

 

 

D7520

Incision and drainage of abscess

$

 

– extraoral soft tissue

 

 

 

 

D7521

Incision and drainage of abscess

$

 

– extraoral soft tissue –

 

 

complicated (includes drainage

 

 

of multiple fascial spaces)

 

 

 

 

D7530

Removal of foreign body from

$

 

 

mucosa, skin, or subcutaneous

 

 

alveolar tissue

 

 

 

 

D7540

Removal of reaction producing

$

 

 

foreign bodies, musculoskeletal

 

 

system

 

 

 

 

D7550

Partial ostectomy /

$

 

 

sequestrectomy for removal of

 

 

non-vital bone

 

 

 

 

D7560

Maxillary sinusotomy for removal

$

 

of tooth fragment or foreign

 

 

body

 

 

 

 

D7610

Maxilla – open reduction (teeth

$

 

 

immobilized, if present)

 

 

 

 

D7620

Maxilla – closed reduction (teeth

$

 

immobilized, if present)

 

 

 

 

D7630

Mandible – open reduction (teeth

$

 

immobilized, if present)

 

 

 

 

D7640

Mandible – closed reduction

$

 

(teeth immobilized, if present)

 

 

 

 

D7650

Malar and/or zygomatic arch –

$

 

open reduction

 

 

 

 

D7660

Malar and/or zygomatic arch –

$

 

closed reduction

 

 

 

 

D7670

Alveolus – closed reduction, may

$

 

include stabilization of teeth

 

 

 

 

D7671

Alveolus – open reduction, may

$

 

include stabilization of teeth

 

 

 

 

D7680

Facial bones – complicated

$

 

reduction with fixation and

 

 

multiple surgical approaches

 

 

 

 

D7710

Maxilla – open reduction

$

 

 

 

D7720

Maxilla – closed reduction

$

 

 

 

D7730

Mandible – open reduction

$

 

 

 

D7740

Mandible – closed reduction

$

 

 

 

D7750

Malar and/or zygomatic arch –

$

 

open reduction

 

 

 

 

D7760

Malar and/or zygomatic arch –

$

 

closed reduction

 

 

 

 

D7770

Alveolus – open reduction

$

 

stabilization of teeth

 

 

 

 

D7771

Alveolus, closed reduction

$

 

stabilization of teeth

 

 

 

 

D7780

Facial bones – complicated

$

 

reduction with fixation and

 

 

multiple surgical approaches

 

 

 

 

D7810

Open reduction of dislocation

$

 

 

 

D7820

Closed reduction of dislocation

$

 

 

 

D7830

Manipulation under anesthesia

$

 

 

 

D7840

Condylectomy

$

 

 

 

D7850

Surgical discectomy,

$

 

with/without implant

 

 

 

 

D7852

Disc repair

$

 

 

 

D7854

Synovectomy

$

 

 

 

D7856

Myotomy

$

 

 

 

D7858

Joint reconstruction

$

 

 

 

D7860

Arthrotomy

$

 

 

 

D7865

Arthroplasty

$

 

 

 

D7870

Arthrocentesis

$

 

 

 

D7871

Non-arthroscopic lysis and

$

 

lavage

 

 

 

 

D7872

Arthroscopy – diagnosis, with or

$

 

without biopsy

 

 

 

 

D7873

Arthroscopy – surgical: lavage

$

 

and lysis of adhesions

 

 

 

 

D7874

Arthroscopy – surgical: disc

$

 

repositioning and stabilization

 

 

 

 

November 2014

D7875

Arthroscopy – surgical:

$

 

synovectomy

 

 

 

 

D7876

Arthroscopy – surgical:

$

 

discectomy

 

 

 

 

D7877

Arthroscopy – surgical:

$

 

debridement

 

 

 

 

D7880

Occlusal orthotic device, by

$

 

report

 

 

 

 

 

D7899

Unspecified TMD therapy, by

$

 

report

 

 

 

 

 

D7910

Suture of recent small wounds

$

 

up to 5 cm

 

 

 

 

D7911

Complicated suture – up to 5 cm

$

 

 

 

D7912

Complicated suture – greater

$

 

than 5 cm

 

 

 

 

D7920

Skin graft (identify defect

$

 

covered, location and type of

 

 

graft)

 

 

 

 

 

D7921

Collection and application of

$

 

autologous blood concentrate

 

 

product

 

 

 

 

 

D7940

Osteoplasty – for orthognathic

$

 

deformities

 

 

 

 

D7941

Osteotomy – mandibular rami

$

 

 

 

D7943

Osteotomy – mandibular rami

$

 

with bone graft; includes

 

 

obtaining the graft

 

 

 

 

D7944

Osteotomy – segmented or

$

 

subapical

 

 

 

 

 

D7945

Osteotomy – body of mandible

$

 

 

 

 

D7946

LeFort I

(maxilla – total)

$

 

 

 

 

D7947

LeFort I

(maxilla – segmented)

$

 

 

 

D7948

LeFort II or LeFort III

$

 

(osteoplasty of facial bones for

 

 

midface hypoplasia or retrusion)

 

 

– without bone graft

 

 

 

 

D7949

LeFort II or LeFort III – with

$

 

bone graft

 

 

 

 

D7950

Osseous, osteoperiosteal, or

$

 

cartilage graft of the mandible or

 

 

maxilla – autogenous or

 

 

nonautogenous, by report

 

 

 

 

D7951

Sinus augmentation with bone or

$

 

bone substitutes via a lateral

 

 

open approach

 

 

 

 

D7952

Sinus augmentation via a vertical

$

 

approach

 

 

 

 

 

D7953

Bone replacement graft for ridge

$

 

preservation – per site

 

 

 

 

D7955

Repair of maxillofacial soft

$

 

and/or hard tissue defect

 

 

 

 

D7960

Frenulectomy – also known as

$

 

frenectomy or frenotomy –

 

 

separate procedure not

 

 

incidental to another procedure

 

 

 

 

D7963

Frenuloplasty

$

 

 

 

D7970

Excision of hyperplastic tissue –

$

 

per arch

 

 

 

 

 

D7971

Excision of pericoronal gingiva

$

 

 

 

D7972

Surgical reduction of fibrous

$

 

tuberosity

 

 

 

 

D7980

Sialolithotomy

$

 

 

 

D7981

Excision of salivary gland, by

$

 

report

 

 

 

 

 

 

Page 8

D7982

Sialodochoplasty

$

 

 

 

D7983

Closure of salivary fistula

$

 

 

 

D7990

Emergency tracheotomy

$

 

 

 

D7991

Coronoidectomy

$

 

 

 

D7995

Synthetic graft – mandible or

$

 

facial bones, by report

 

 

 

 

D7996

Implant – mandible for

$

 

augmentation purposes

 

 

(excluding alveolar ridge), by

 

 

report

 

 

 

 

D7997

Appliance removal (not by

$

 

dentist who placed appliance),

 

 

includes removal of archbar

 

 

 

 

D7998

Intraoral placement of a fixation

$

 

device not in conjunction with a

 

 

fracture

 

 

 

 

D7999

Unspecified oral surgery

$

 

procedure, by report

 

 

 

 

XI. ORTHODONTICS

 

 

 

 

D8010

Limited orthodontic treatment of

$

 

the primary dentition

 

 

 

 

D8020

Limited orthodontic treatment of

$

 

the transitional dentition

 

 

 

 

D8030

Limited orthodontic treatment of

$

 

the adolescent dentition

 

 

 

 

D8040

Limited orthodontic treatment of

$

 

the adult dentition

 

 

 

 

D8050

Interceptive orthodontic

$

 

treatment of the primary

 

 

dentition

 

 

 

 

D8060

Interceptive orthodontic

$

 

treatment of the transitional

 

 

dentition

 

 

 

 

D8070

Comprehensive orthodontic

$

 

treatment of the transitional

 

 

dentition

 

 

 

 

D8080

Comprehensive orthodontic

$

 

treatment of the adolescent

 

 

dentition

 

 

 

 

D8090

Comprehensive orthodontic

$

 

treatment of the adult dentition

 

 

 

 

D8210

Removable appliance therapy

$

 

 

 

D8220

Fixed appliance therapy

$

 

 

 

D8660

Pre-orthodontic treatment

$

 

examination to monitor growth

 

 

and development

 

 

 

 

D8670

Periodic orthodontic treatment

$

 

visit

 

 

 

 

D8680

Orthodontic retention (removal

$

 

of appliances, construction and

 

 

placement of retainer(s))

 

 

 

 

D8690

Orthodontic treatment

$

 

(alternative billing to a contract

 

 

fee)

 

 

 

 

D8691

Repair of orthodontic appliance

$

 

 

 

D8692

Replacement of lost or broken

$

 

retainer

 

 

 

 

D8693

Re–cement or re-bond fixed

$

 

retainer

 

 

 

 

D8694

Repair of fixed retainers, includes

$

 

reattachment

 

 

 

 

D8999

Unspecified orthodontic

$

 

procedure, by report

 

 

 

 

XII. ADJUNCTIVE GENERAL SERVICES

D9110

Palliative (emergency) treatment

$

 

of dental pain – minor procedure

 

 

 

 

D9120

Fixed partial denture sectioning

$

 

 

 

D9210

Local anesthesia not in

$

 

conjunction with operative or

 

 

surgical procedures

 

 

 

 

D9211

Regional block anesthesia

$

 

 

 

D9212

Trigeminal division block

$

 

anesthesia

 

 

 

 

D9215

Local anesthesia in conjunction

$

 

with operative or surgical

 

 

procedures

 

 

 

 

D9219

Evaluation for deep sedation or

$

 

general anesthesia

 

 

 

 

D9220

Deep sedation/general

$

 

anesthesia – first 30 minutes

 

 

 

 

D9221

Deep sedation/general

$

 

anesthesia – each additional 15

 

 

minutes

 

 

 

 

D9230

Inhalation of nitrous

$

 

oxide/analgesia, anxiolysis

 

 

 

 

D9241

Intravenous moderate

$

 

(conscious) sedation/analgesia –

 

 

first 30 minutes

 

 

 

 

D9242

Intravenous moderate

$

 

(conscious) sedation/analgesia –

 

 

each additional 15 minutes

 

 

 

 

D9248

Non-intravenous moderate

$

 

(conscious) sedation

 

 

 

 

D9310

Consultation – diagnostic service

$

 

provided by dentist or physician

 

 

other than requesting dentist or

 

 

physician

 

 

 

 

D9410

House/extended care facility call

$

 

 

 

D9420

Hospital or ambulatory surgical

$

 

center call

 

 

 

 

D9430

Office visit for observation

$

 

(during regularly scheduled

 

 

hours) – no other services

 

 

performed

 

 

 

 

D9440

Office visit – after regularly

$

 

scheduled hours

 

 

 

 

D9450

Case presentation, detailed and

$

 

extensive treatment planning

 

 

 

 

D9610

Therapeutic parenteral drug,

$

 

single administration

 

 

 

 

D9612

Therapeutic parenteral drugs,

$

 

two or more administrations,

 

 

different medications

 

 

 

 

D9630

Other drugs and/or

$

 

medicaments, by report

 

 

 

 

D9910

Application of desensitizing

$

 

medicament

 

 

 

 

D9911

Application of desensitizing resin

$

 

for cervical and/or root surface,

 

 

per tooth

 

 

 

 

D9920

Behavior management, by report

$

 

 

 

D9930

Treatment of complications

$

 

(post-surgical) – unusual

 

 

circumstances, by report

 

 

 

 

D9931

Cleaning and inspection of a

$

 

removable appliance

 

 

 

 

D9940

Occlusal guard, by report

$

 

 

 

November 2014

D9941

Fabrication of athletic

$

 

mouthguard

 

 

 

 

D9942

Repair and/or reline of occlusal

$

 

guard

 

 

 

 

D9950

Occlusion analysis – mounted

$

 

case

 

 

 

 

D9951

Occlusal adjustment – limited

$

 

 

 

D9952

Occlusal adjustment – complete

$

 

 

 

D9970

Enamel microabrasion

$

 

 

 

D9971

Odontoplasty 1 – 2 teeth;

$

 

includes removal of enamel

 

 

projections

 

 

 

 

D9972

External bleaching – per arch

$

 

performed in office

 

 

 

 

D9973

External bleaching – per tooth

$

 

 

 

D9974

Internal bleaching – per tooth

$

 

 

 

D9975

External bleaching for home

$

 

application, per arch; includes

 

 

materials and fabrication of

 

 

custom trays

 

 

 

 

D9985

Sales tax

$

 

 

 

D9986

Missed appointment

$

 

 

 

D9987

Cancelled appointment

$

 

 

 

D9999

Unspecified adjunctive

$

 

procedure, by report

 

 

 

 

Page 9

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