Dental Reimbursement Rates

D0001 — Dental Procedure, By Report D0120 — Periodic Oral Evaluation D0140 — Limited Oral Evaluation — Problem Focused D0145 — Oral Evaluation for Patient Under 3 D0150 — Comprehensive Oral Evaluation — New/Established D0160 — Detailed/Extensive Oral Evaluation D0170 — Re-evaluation — Limited, Problem Focused D0171 — Re-evaluation — Post-Operative D0180 — Comprehensive Periodontal Evaluation D0190 — Screening of a Patient D0191 — Assessment of a Patient D0210 — Full Mouth X-Rays D0220 — Periapical X-Ray — First Film D0230 — Periapical X-Ray — Each Additional Film D0240 — Occlusal X-Ray D0250 — Extraoral — 2D Projection D0251 — Extraoral — Posterior Dental X-Ray D0270 — Bitewing X-Ray — Single Film D0272 — Bitewing X-Rays — Two Films D0273 — Bitewing X-Rays — Three Films D0274 — Bitewing X-Rays — Four Films D0277 — Vertical Bitewing X-Rays (7–8 Films) D0310 — Sialography D0320 — TMJ Arthrogram D0321 — Other TMJ Films D0322 — Tomographic Survey D0330 — Panoramic X-Ray D0340 — 2D Cephalometric X-Ray D0350 — Oral/Facial Photographic Images D0364 — Cone Beam CT — Limited Field (<1 Jaw) D0365 — Cone Beam CT — Single Jaw (Partial) D0366 — Cone Beam CT — Single Jaw (Full) D0367 — Cone Beam CT — Both Jaws (Partial) D0368 — Cone Beam CT — Both Jaws (Full) D0369 — Cone Beam CT — Maxillofacial D0370 — Cone Beam CT — Image Capture (Limited) D0371 — Cone Beam CT — Interpretation (Limited) D0372 — Cone Beam CT — 3D Data Capture (Both Jaws) D0373 — Cone Beam CT — 3D Interpretation (Both Jaws) D0374 — Cone Beam CT — 3D Re-formatting D0380 — Cone Beam CT Image Capture D0381 — Cone Beam CT — Other Capture D0382 — Cone Beam CT — Other Interpretation D0383 — Cone Beam CT — Other Re-formatting D0384 — Cone Beam CT — Surgical Guide Fabrication D0385 — Cone Beam CT — Maxillofacial Image Capture D0386 — Cone Beam CT — Maxillofacial Interpretation D0387 — Cone Beam CT — Maxillofacial Re-formatting D0388 — Cone Beam CT — Airway Assessment Image Capture D0389 — Cone Beam CT — Airway Assessment Interpretation D0391 — Interpretation of Diagnostic Image (Another Dentist) D0393 — Treatment Simulation (3D) D0394 — Digital Subtraction of Two Radiographs D0395 — Fusion of Two or More 3D Volumes D0396 — 3D Volume Rendering of Image Data D0411 — HbA1c In-Office Point-of-Care Test D0412 — Blood Glucose In-Office Test D0414 — Lab Processing of Microbial Specimen D0415 — Collection of Microbial Culture Specimen D0416 — Viral Culture Specimen Collection D0417 — Collection of Saliva for Lab Analysis D0418 — Analysis of Saliva Specimen D0419 — Biofilm Pathogen Assessment D0422 — Caries Risk Assessment (Under 6) D0423 — Caries Risk Assessment (6 & Older) D0425 — Caries Susceptibility Test D0426 — Caries Risk Assessment & Documentation (Low Risk) D0431 — Adjunctive Pre-Diagnostic Test (No Biopsy) D0460 — Pulp Vitality Test D0461 — Pulp Vitality Test — Multiple Teeth D0470 — Diagnostic Cast D0472 — Accession of Tissue (Gross Exam Only) D0473 — Accession of Tissue (Gross & Micro Exam) D0474 — Accession of Tissue (Decalcification) D0475 — Decalcification Procedure D0476 — Special Stain (Not Part of Routine) D0477 — Consultation (Pathologist, Submitted Specimen) D0478 — Consultation (Pathologist, Outside Material) D0479 — Pathology Consultation (External Slides) D0480 — Accession of Exfoliative Cytologic Smears D0481 — Electron Microscopy — Diagnostic D0482 — Direct Immunofluorescence D0483 — Indirect Immunofluorescence D0484 — Histopathology — Consultation (Report) D0485 — Consultation on Referred Specimens D0486 — Accession of Transepithelial Cytologic Sample D0502 — Other Oral Pathology Procedure D0600 — Non-Ionizing Diagnostic Procedure D0601 — Caries Risk Assessment — Low Risk D0602 — Caries Risk Assessment — Moderate Risk D0603 — Caries Risk Assessment — High Risk D0604 — D0604 D0605 — D0605 D0701 — Panoramic Radiographic Image D0702 — 2D Cephalometric Radiographic Image D0703 — 2D Oral/Facial Photographic Image D0705 — D0705 D0706 — Intraoral — Occlusal Radiographic Image D0707 — Intraoral — Periapical Radiographic Image D0708 — D0708 D0709 — Intraoral — Complete Series Radiographic Images D0801 — 3D Surface Scan — Pre-Ortho D0802 — 3D Surface Scan — Post-Ortho D0803 — 3D Surface Scan — Pre-Restorative D0804 — 3D Surface Scan — Post-Restorative D0999 — Unspecified Diagnostic Procedure, By Report

D1110 — Adult Prophylaxis (Cleaning) D1120 — Child Prophylaxis D1206 — Fluoride Varnish Treatment D1208 — Fluoride Application (Excluding Varnish) D1301 — Panoramic Radiograph for Caries Risk D1310 — Nutritional Counseling for Dental Caries D1320 — Tobacco Counseling for Oral Health D1321 — Counseling for Substance Abuse D1330 — Oral Hygiene Instructions D1351 — Dental Sealant — Per Tooth D1353 — Sealant Repair — Per Tooth D1354 — Interim Caries Arresting Medicament (SDF) D1355 — Caries Preventive Medicament Application D1510 — Space Maintainer — Fixed, Unilateral D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1520 — Space Maintainer — Removable, Unilateral D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1527 — Space Maintainer — Removable, Bilateral (Mandibular) D1551 — Re-cement/Re-bond Space Maintainer (Unilateral) D1552 — Re-cement/Re-bond Space Maintainer (Bilateral, Max) D1553 — Re-cement/Re-bond Space Maintainer (Bilateral, Mand) D1556 — Removal of Fixed Space Maintainer (Unilateral) D1557 — Removal of Fixed Space Maintainer (Bilateral, Max) D1558 — Removal of Fixed Space Maintainer (Bilateral, Mand) D1575 — Distal Shoe Space Maintainer D1720 — D1720 D1781 — D1781 D1782 — D1782 D1783 — D1783 D1999 — Unspecified Preventive Procedure, By Report

D2140 — Amalgam Filling — 1 Surface, Primary/Permanent D2150 — Amalgam Filling — 2 Surfaces, Primary/Permanent D2160 — Amalgam Filling — 3 Surfaces, Primary/Permanent D2161 — Amalgam Filling — 4+ Surfaces, Primary/Permanent D2330 — Composite Filling — 1 Surface, Anterior D2331 — Composite Filling — 2 Surfaces, Anterior D2332 — Composite Filling — 3 Surfaces, Anterior D2335 — Composite Filling — 4+ Surfaces/Incisal Angle D2390 — Composite Crown — Anterior, Primary D2391 — Composite Filling — 1 Surface, Posterior D2392 — Composite Filling — 2 Surfaces, Posterior D2393 — Composite Filling — 3 Surfaces, Posterior D2394 — Composite Filling — 4+ Surfaces, Posterior D2410 — Gold Foil — 1 Surface D2420 — Gold Foil — 2 Surfaces D2430 — Gold Foil — 3 Surfaces D2510 — Inlay — Metallic, 1 Surface D2520 — Inlay — Metallic, 2 Surfaces D2530 — Inlay — Metallic, 3+ Surfaces D2542 — Onlay — Metallic, 2 Surfaces D2543 — Onlay — Metallic, 3 Surfaces D2544 — Onlay — Metallic, 4+ Surfaces D2610 — Inlay — Porcelain/Ceramic, 1 Surface D2620 — Inlay — Porcelain/Ceramic, 2 Surfaces D2630 — Inlay — Porcelain/Ceramic, 3+ Surfaces D2642 — Onlay — Porcelain/Ceramic, 2 Surfaces D2643 — Onlay — Porcelain/Ceramic, 3 Surfaces D2644 — Onlay — Porcelain/Ceramic, 4+ Surfaces D2650 — Inlay — Composite/Resin, 1 Surface D2651 — Inlay — Composite/Resin, 2 Surfaces D2652 — Inlay — Composite/Resin, 3+ Surfaces D2662 — Onlay — Composite/Resin, 2 Surfaces D2663 — Onlay — Composite/Resin, 3 Surfaces D2664 — Onlay — Composite/Resin, 4+ Surfaces D2710 — Crown — Resin (Indirect) D2712 — Crown — ¾ Resin (Indirect) D2720 — Crown — Resin with High Noble Metal D2721 — Crown — Resin with Base Metal D2722 — Crown — Resin with Noble Metal D2740 — Crown — Porcelain/Ceramic D2750 — Crown — Porcelain Fused to High Noble Metal D2751 — Crown — Porcelain Fused to Base Metal D2752 — Crown — Porcelain Fused to Noble Metal D2753 — Crown — Porcelain Fused to Titanium D2780 — Crown — ¾ Cast High Noble Metal D2781 — Crown — ¾ Cast Base Metal D2782 — Crown — ¾ Cast Noble Metal D2783 — Crown — ¾ Porcelain/Ceramic D2790 — Crown — Full Cast High Noble Metal D2791 — Crown — Full Cast Base Metal D2792 — Crown — Full Cast Noble Metal D2794 — Crown — Titanium D2799 — Provisional Crown D2910 — Re-cement/Re-bond Inlay, Onlay, Veneer, or Partial D2915 — Re-cement/Re-bond Cast or Prefab Post & Core D2920 — Re-cement/Re-bond Crown D2921 — Reattachment of Tooth Fragment D2928 — Prefabricated Porcelain/Ceramic Crown — Primary D2929 — Prefabricated Porcelain/Ceramic Crown — Permanent D2930 — Prefabricated Stainless Steel Crown — Primary D2931 — Prefabricated Stainless Steel Crown — Permanent D2932 — Prefabricated Resin Crown D2933 — Prefabricated SS Crown with Resin Window D2934 — Prefabricated Esthetic Coated SS Crown — Primary D2940 — Protective Restoration (Sedative Filling) D2949 — Restorative Foundation for Crown D2950 — Core Buildup Including Pins D2951 — Pin Retention — Per Tooth D2952 — Post and Core — Cast (w/ Crown) D2953 — Post and Core — Each Additional (Cast) D2954 — Prefabricated Post and Core D2955 — Post Removal D2956 — Prefabricated Post and Core — Additional D2957 — Each Additional Prefabricated Post D2960 — Labial Veneer — Resin (Chair-side) D2961 — Labial Veneer — Resin (Lab) D2962 — Labial Veneer — Porcelain (Lab) D2971 — Additional Procedures for Crown (Specify) D2975 — Coping D2976 — Stump Buildup with Pins D2980 — Crown Repair, By Report D2981 — Inlay Repair, By Report D2982 — Onlay Repair, By Report D2983 — Veneer Repair, By Report D2989 — Unspecified Restorative Procedure, By Report D2990 — Resin Infiltration of Incipient Lesion D2991 — Mineral Infiltration of Incipient Lesion D2999 — Unspecified Restorative Procedure, By Report

D3110 — Pulp Cap — Direct (Excluding Final Restoration) D3120 — Pulp Cap — Indirect (Excluding Final Restoration) D3220 — Therapeutic Pulpotomy (Excluding Final Restoration) D3221 — Pulpal Debridement — Primary/Permanent Teeth D3222 — Partial Pulpotomy for Apexogenesis — Permanent D3230 — Pulpal Therapy — Anterior, Primary D3240 — Pulpal Therapy — Posterior, Primary D3310 — Root Canal — Anterior (Excluding Final Restoration) D3320 — Root Canal — Premolar (Excluding Final Restoration) D3330 — Root Canal — Molar (Excluding Final Restoration) D3331 — Treatment of Root Canal Obstruction (Non-Surgical) D3332 — Incomplete Endodontic Treatment (Inoperable/Fracture) D3333 — Internal Root Repair — Perforation D3346 — Retreatment — Anterior D3347 — Retreatment — Premolar D3348 — Retreatment — Molar D3351 — Apexification/Recalcification — Initial Visit D3352 — Apexification/Recalcification — Interim Medication D3353 — Apexification/Recalcification — Final Visit D3355 — Pulpal Regeneration — Initial Visit D3356 — Pulpal Regeneration — Interim Medication D3357 — Pulpal Regeneration — Final Visit D3410 — Apicoectomy — Anterior D3421 — Apicoectomy — Premolar (First Root) D3425 — Apicoectomy — Molar (First Root) D3426 — Apicoectomy — Each Additional Root D3428 — Retrograde Filling — Per Root D3429 — Hemisection (Including Root Removal, Not Crown) D3430 — Retrograde Filling — Per Root D3431 — Biologically-Based Root Treatment D3432 — Guided Tissue Regeneration (Periradicular Surgery) D3450 — Root Amputation — Per Root D3460 — Endodontic Implant (Endosteal) D3470 — Intentional Reimplantation D3471 — Surgical Repair — Root Resorption (Anterior) D3472 — Surgical Repair — Root Resorption (Premolar) D3473 — Surgical Repair — Root Resorption (Molar) D3501 — Surgical Exposure for Canal Access D3502 — Surgical Perforation Repair D3503 — Surgical Root Repair — Anterior D3910 — Surgical Procedure for Isolation of Tooth D3911 — Endodontic Re-opening for Drainage D3920 — Hemisection (Not Root Canal/Restoration) D3921 — Decoronation/Intentional Submergence D3950 — Canal Prep and Fitting of Preformed Post/Dowel D3999 — Unspecified Endodontic Procedure, By Report

D4210 — Gingivectomy/Gingivoplasty — 4+ Teeth (Per Quad) D4211 — Gingivectomy/Gingivoplasty — 1–3 Teeth (Per Quad) D4212 — Gingivectomy/Gingivoplasty (Restorative, Per Tooth) D4230 — Anatomical Crown Exposure — 4+ Teeth (Per Quad) D4231 — Anatomical Crown Exposure — 1–3 Teeth (Per Quad) D4240 — Gingival Flap Surgery — 4+ Teeth (Per Quad) D4241 — Gingival Flap Surgery — 1–3 Teeth (Per Quad) D4245 — Apically Positioned Flap D4249 — Clinical Crown Lengthening — Hard Tissue D4260 — Osseous Surgery — 4+ Teeth (Per Quad) D4261 — Osseous Surgery — 1–3 Teeth (Per Quad) D4263 — Bone Replacement Graft — First Site (Per Quad) D4264 — Bone Replacement Graft — Each Additional Site D4265 — Biologic Material for Tissue Regeneration D4266 — Guided Tissue Regeneration — Resorbable Barrier D4267 — Guided Tissue Regeneration — Non-Resorbable Barrier D4268 — Surgical Revision (Failed Previous Graft Site) D4270 — Pedicle Soft Tissue Graft D4273 — Autogenous Connective Tissue Graft (First Tooth) D4274 — Distal/Proximal Wedge Procedure D4275 — Non-Autogenous Connective Tissue Graft (First Tooth) D4276 — Combined Connective Tissue & Pedicle Graft D4277 — Free Soft Tissue Graft (First Tooth) D4278 — Free Soft Tissue Graft (Each Additional Tooth) D4283 — Autogenous Connective Tissue Graft (Each Add'l Tooth) D4285 — Non-Autogenous Connective Tissue Graft (Each Add'l) D4286 — Combined Connective Tissue Graft (Each Add'l Tooth) D4322 — Splint — Intracoronal (Natural Teeth) D4323 — Splint — Extracoronal (Natural Teeth) D4341 — Scaling and Root Planing — 4+ Teeth (Per Quad) D4342 — Scaling and Root Planing — 1–3 Teeth (Per Quad) D4346 — Scaling — Generalized Moderate/Severe Gingivitis D4355 — Full Mouth Debridement D4381 — Localized Antimicrobial Delivery (Per Tooth) D4910 — Periodontal Maintenance D4920 — Unscheduled Dressing Change D4921 — Gingival Irrigation — Per Quadrant D4999 — Unspecified Periodontal Procedure, By Report

D5110 — Complete Upper Denture D5120 — Complete Lower Denture D5130 — Immediate Upper Denture D5140 — Immediate Lower Denture D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5213 — Upper Partial Denture — Cast Metal Framework D5214 — Lower Partial Denture — Cast Metal Framework D5221 — Immediate Upper Partial Denture — Resin Base D5222 — Immediate Lower Partial Denture — Resin Base D5223 — Immediate Upper Partial Denture — Cast Metal D5224 — Immediate Lower Partial Denture — Cast Metal D5225 — Upper Partial Denture — Flexible Base D5226 — Lower Partial Denture — Flexible Base D5227 — Immediate Upper Partial Denture — Flexible Base D5228 — Immediate Lower Partial Denture — Flexible Base D5280 — D5280 D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5410 — Adjust Complete Upper Denture D5411 — Adjust Complete Lower Denture D5421 — Adjust Partial Upper Denture D5422 — Adjust Partial Lower Denture D5511 — Repair Broken Complete Denture Base (Upper) D5512 — Repair Broken Complete Denture Base (Lower) D5520 — Replace Missing/Broken Teeth — Complete Denture D5611 — Repair Resin Partial Denture Base (Upper) D5612 — Repair Resin Partial Denture Base (Lower) D5621 — Repair Cast Partial Framework (Upper) D5622 — Repair Cast Partial Framework (Lower) D5630 — Repair or Replace Broken Clasp — Per Tooth D5640 — Replace Broken Teeth — Per Tooth D5650 — Add Tooth to Existing Partial Denture D5660 — Add Clasp to Existing Partial Denture D5670 — Replace Teeth & Acrylic on Metal Framework D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5710 — Rebase Complete Upper Denture D5711 — Rebase Complete Lower Denture D5720 — Rebase Upper Partial Denture D5721 — Rebase Lower Partial Denture D5725 — Rebase Hybrid Prosthesis D5730 — Reline Complete Upper Denture (Chair-side) D5731 — Reline Complete Lower Denture (Chair-side) D5740 — Reline Upper Partial Denture (Chair-side) D5741 — Reline Lower Partial Denture (Chair-side) D5750 — Reline Complete Upper Denture (Lab) D5751 — Reline Complete Lower Denture (Lab) D5760 — Reline Upper Partial Denture (Lab) D5761 — Reline Lower Partial Denture (Lab) D5765 — Soft Liner for Complete or Partial Denture D5810 — Interim Complete Upper Denture D5811 — Interim Complete Lower Denture D5820 — Interim Partial Upper Denture D5821 — Interim Partial Lower Denture D5850 — Tissue Conditioning (Upper) D5851 — Tissue Conditioning (Lower) D5862 — Precision Attachment — By Report D5863 — Overdenture — Complete (Implant/Root Supported) D5864 — Overdenture — Partial (Implant/Root Supported) D5865 — Overdenture — Complete (Implant Supported) D5866 — Overdenture — Partial (Implant Supported) D5867 — Replacement of Attachment — Implant Overdenture D5875 — Modification of Removable Prosthesis (Implant) D5876 — Add Metal Substructure to Acrylic Denture D5877 — Replacement of Locator Male, By Report D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5899 — Unspecified Removable Prosthodontic Procedure D5909 — Removable Prosthesis Adjustment, By Report 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 Prosthesis D5926 — Nasal Prosthesis (Replacement) D5927 — Auricular Prosthesis (Replacement) D5928 — Orbital Prosthesis (Replacement) D5929 — Facial Prosthesis (Replacement) D5930 — Obturator — Surgical D5931 — Obturator — Modified Surgical D5932 — Obturator — Definitive D5933 — Obturator — Modification (Surgical/Definitive) D5934 — Mandibular Resection Prosthesis (w/o Guide Flange) D5935 — Mandibular Resection Prosthesis (w/ Guide Flange) D5936 — Obturator — Interim D5937 — Trismus Appliance (Not for TDJ Treatment) D5938 — Trismus Appliance — With Expansion Capability D5939 — Trismus Appliance — Without Expansion D5940 — Connector Bar — Implant Supported D5941 — Interim Obturator — Adjustment D5942 — Adjustment to Mandibular Resection Prosthesis D5943 — Replacement Obturator Prosthesis (Surgical) D5944 — Replacement Obturator Prosthesis (Modified Surgical) D5945 — Replacement Obturator Prosthesis (Definitive) D5946 — Replacement Mandibular Resection — w/o Flange D5947 — Replacement Mandibular Resection — w/ Flange D5948 — Radiation Carrier/Positioner D5949 — Radiation Shield/Guard D5951 — Feeding Aid (Obturator) 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 Stent D5984 — Radiation Cone Locator D5985 — Radiation Shield D5986 — Fluoride Gel Carrier D5987 — Commissure Splint D5988 — Surgical Splint D5991 — Vesiculobullous Disease Medicament Carrier D5992 — Adjust Maxillofacial Prosthetic Appliance D5993 — Maintenance/Cleaning of Maxillofacial Prosthesis D5995 — Periodontal Medicament Carrier (Lab-Processed) D5996 — Interim Obturator (Cleft Palate) D5999 — Unspecified Maxillofacial Prosthetic Procedure

D6010 — Surgical Placement — Endosteal Implant Body D6011 — Second Stage Implant Surgery D6012 — Surgical Placement — Interim Implant Body D6013 — Surgical Placement — Mini Implant D6040 — Surgical Placement — Eposteal Implant D6049 — Removable Implant Prosthesis, By Report D6050 — Custom Fabricated Implant Abutment D6051 — Interim Implant Abutment D6055 — Dental Implant-Supported Connecting Bar D6056 — Prefabricated Implant Abutment D6057 — Custom Fabricated Implant Abutment D6058 — Implant Abutment — Prefabricated D6059 — Implant Abutment — Custom, By Report D6060 — Implant Abutment — Prefabricated (Noble Metal) D6061 — Implant Abutment — Prefabricated (Base Metal) D6062 — Implant Abutment — Cast-to (Noble Metal) D6063 — Implant Abutment — Cast-to (Base Metal) D6064 — Implant Abutment — Prefabricated (Titanium) D6065 — Implant Crown — Porcelain/Ceramic D6066 — Implant Crown — Porcelain Fused to Metal D6067 — Implant Crown — High Noble Metal D6068 — Implant Abutment — Prefabricated D6069 — Implant Crown — Titanium D6070 — Implant Crown — Cast High Noble Metal D6071 — Implant Crown — Cast Base Metal D6072 — Implant Bridge Pontic — Porcelain Fused to Metal D6073 — Implant Bridge Pontic — Cast High Noble Metal D6074 — Implant Bridge Pontic — Porcelain/Ceramic D6075 — Implant Crown — Porcelain Fused to Titanium D6076 — Implant Crown — Base Metal D6077 — Implant Crown — Noble Metal D6080 — Implant Maintenance — Cleaning/Inspection D6081 — Scaling/Debridement of Implant (Moderate/Severe) D6082 — Implant-Supported Crown Repair, By Report D6083 — Implant-Supported Prosthesis Repair, By Report D6084 — Custom Implant Abutment (Porcelain/Ceramic) D6085 — Provisional Implant Crown D6086 — Implant Crown — Resin D6087 — Implant Bridge Pontic — Resin D6088 — Implant Bridge Retainer — Resin D6089 — Implant Abutment Modification D6090 — Repair Implant-Supported Prosthesis, By Report D6091 — Implant Repair — Abutment Replacement D6092 — Re-cement/Re-bond Implant Crown D6093 — Re-cement/Re-bond Implant Bridge D6094 — Implant Abutment — Titanium/Ti Alloy (Custom) D6096 — Remove Broken Implant Retaining Screw D6097 — Abutment-Supported Retainer (Removable) D6098 — Implant-Supported Retainer (Removable) D6099 — Implant-Supported Retainer for FPD (Ceramic) D6100 — Implant Removal D6101 — Debridement of Peri-Implant Defect — Surgical D6102 — Bone Graft — Debridement of Peri-Implant Defect D6103 — Bone Graft — Implant Repair (First Site) D6104 — Bone Graft — Implant Repair (Each Add'l Site) D6105 — Bone Graft — Mandibular Ramus D6106 — Bone Graft — Mandibular Symphysis D6107 — Bone Graft — From Extra-Oral Donor Site D6110 — Implant Bridge Retainer — Porcelain Fused to HNM D6111 — Implant Bridge Retainer — Porcelain Fused to BM D6112 — Implant Bridge Retainer — Porcelain/Ceramic D6113 — Implant Bridge Retainer — Cast Metal (HNM) D6114 — Implant Bridge Retainer — Cast Metal (NM) D6115 — Implant Bridge Retainer — Cast Metal (BM) D6116 — Implant Bridge Retainer — Porcelain Fused to Ti D6117 — Implant Bridge Retainer — Titanium D6118 — Implant Bridge Retainer — Resin (Indirect) D6119 — Implant Bridge Retainer — Porcelain Fused to NM D6120 — Implant-Supported Retainer — FPD (High Noble) D6121 — Implant-Supported Retainer — FPD (Noble) D6122 — Implant-Supported Retainer — FPD (Base) D6123 — Implant-Supported Retainer — FPD (Titanium) D6180 — Implant-Supported Partial Denture (Upper) D6190 — Radiographic/Surgical Implant Index (Per Arch) D6191 — Semi-Precision Abutment — Placement D6192 — Semi-Precision Abutment — Removal D6193 — Stress-Breaking Abutment — Placement D6194 — Stress-Breaking Abutment — Removal D6195 — Implant-Supported Connector Bar (Modification) D6196 — Implant Provisional Crown (Implant Placement Visit) D6197 — Replacement of Attachment for Implant Denture D6198 — Remove Interim Implant Body D6199 — Unspecified Implant Procedure, By Report D6205 — Bridge Pontic — Indirect Composite/Resin D6210 — Bridge Pontic — Cast High Noble Metal D6211 — Bridge Pontic — Cast Base Metal D6212 — Bridge Pontic — Cast Noble Metal D6214 — Bridge Pontic — Titanium D6240 — Bridge Pontic — Porcelain Fused to High Noble Metal D6241 — Bridge Pontic — Porcelain Fused to Base Metal D6242 — Bridge Pontic — Porcelain Fused to Noble Metal D6243 — Bridge Pontic — Porcelain Fused to Titanium D6245 — Bridge Pontic — Porcelain/Ceramic D6250 — Bridge Pontic — Resin with High Noble Metal D6251 — Bridge Pontic — Resin with Base Metal D6252 — Bridge Pontic — Resin with Noble Metal D6253 — Provisional Bridge Pontic D6280 — Bridge Pontic — Resin/Acrylic Denture Tooth D6545 — Retainer — Cast Metal for Resin-Bonded Bridge D6548 — Retainer — Porcelain/Ceramic for Resin-Bonded Bridge D6549 — Retainer — Resin for Resin-Bonded Bridge D6600 — Bridge Retainer — Inlay, Porcelain/Ceramic (2 Surf) D6601 — Bridge Retainer — Inlay, Porcelain/Ceramic (3+ Surf) D6602 — Bridge Retainer — Inlay, Cast High Noble Metal (2 Surf) D6603 — Bridge Retainer — Inlay, Cast High Noble Metal (3+ Surf) D6604 — Bridge Retainer — Inlay, Cast Base Metal (2 Surf) D6605 — Bridge Retainer — Inlay, Cast Base Metal (3+ Surf) D6606 — Bridge Retainer — Inlay, Cast Noble Metal (2 Surf) D6607 — Bridge Retainer — Inlay, Cast Noble Metal (3+ Surf) D6608 — Bridge Retainer — Onlay, Porcelain/Ceramic (2 Surf) D6609 — Bridge Retainer — Onlay, Porcelain/Ceramic (3+ Surf) D6610 — Bridge Retainer — Onlay, Cast High Noble Metal (2 Surf) D6611 — Bridge Retainer — Onlay, Cast High Noble Metal (3+ Surf) D6612 — Bridge Retainer — Onlay, Cast Base Metal (2 Surf) D6613 — Bridge Retainer — Onlay, Cast Base Metal (3+ Surf) D6614 — Bridge Retainer — Onlay, Cast Noble Metal (2 Surf) D6615 — Bridge Retainer — Onlay, Cast Noble Metal (3+ Surf) D6624 — Bridge Retainer — Inlay, Titanium D6634 — Bridge Retainer — Onlay, Titanium D6710 — Bridge Retainer — Indirect Resin D6720 — Bridge Retainer — Resin with High Noble Metal D6721 — Bridge Retainer — Resin with Base Metal D6722 — Bridge Retainer — Resin with Noble Metal D6740 — Bridge Retainer — Porcelain/Ceramic D6750 — Bridge Retainer — Porcelain Fused to High Noble Metal D6751 — Bridge Retainer — Porcelain Fused to Base Metal D6752 — Bridge Retainer — Porcelain Fused to Noble Metal D6753 — Bridge Retainer — Porcelain Fused to Titanium D6780 — Bridge Retainer — ¾ Cast High Noble Metal D6781 — Bridge Retainer — ¾ Cast Base Metal D6782 — Bridge Retainer — ¾ Cast Noble Metal D6783 — Bridge Retainer — ¾ Porcelain/Ceramic D6784 — Bridge Retainer — ¾ Titanium D6790 — Bridge Retainer — Full Cast High Noble Metal D6791 — Bridge Retainer — Full Cast Base Metal D6792 — Bridge Retainer — Full Cast Noble Metal D6793 — Bridge Retainer — Full Cast Titanium D6794 — Bridge Retainer — Titanium D6920 — Connector Bar D6930 — Re-cement/Re-bond Bridge D6940 — Bridge Repair, By Report D6950 — Precision Attachment D6980 — Fixed Partial Denture Repair, By Report D6985 — Pediatric Partial Denture — Fixed D6999 — Unspecified Fixed Prosthodontic Procedure

D7111 — Extraction — Coronal Remnants (Primary Tooth) D7140 — Extraction — Erupted Tooth or Exposed Root D7210 — Extraction — Surgical (Erupted Tooth) D7220 — Extraction — Soft Tissue Impacted Tooth D7230 — Extraction — Partially Bony Impacted Tooth D7240 — Extraction — Completely Bony Impacted Tooth D7241 — Extraction — Completely Bony Impacted (Complicated) D7250 — Extraction — Residual Root Removal D7251 — Coronectomy — Intentional Partial Tooth Removal D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7259 — D7259 D7260 — Oroantral Fistula Closure D7261 — Primary Closure of Sinus Perforation D7270 — Tooth Reimplantation/Stabilization D7272 — Tooth Transplantation D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7282 — Mobilization of Erupted/Malpositioned Tooth D7283 — Placement of Device for Eruption of Impacted Tooth D7284 — Excisional Biopsy — Bone D7285 — Incisional Biopsy — Oral Tissue (Hard) D7286 — Incisional Biopsy — Oral Tissue (Soft) D7287 — Exfoliative Cytological Sample Collection D7288 — Brush Biopsy — Transepithelial Sample Collection D7290 — Surgical Repositioning of Teeth D7291 — Transseptal Fiberotomy D7292 — Surgical Placement — Temporary Anchorage Device D7293 — Surgical Placement — Temporary Anchorage (Requiring Flap) D7294 — Surgical Placement — Temporary Anchorage (Requiring Flap, Bone) D7295 — Harvest of Bone for Graft D7296 — Corticotomy — One to Three Tooth Spaces D7297 — Corticotomy — Four or More Tooth Spaces D7298 — Removal of Temporary Anchorage Device D7299 — Unspecified Oral Surgery Procedure, By Report D7300 — Removal of Foreign Body from Mucosa/Skin/Subcut D7310 — Alveoloplasty — With Extractions (Per Quad) D7311 — Alveoloplasty — With Extractions (1–3 Teeth) D7320 — Alveoloplasty — Without Extractions (Per Quad) D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7340 — Vestibuloplasty — Ridge Extension D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7410 — Excision of Benign Lesion ≤ 1.25 cm D7411 — Excision of Benign Lesion > 1.25 cm D7412 — Excision of Benign Lesion — Complicated D7413 — Excision of Malignant Lesion ≤ 1.25 cm D7414 — Excision of Malignant Lesion > 1.25 cm D7415 — Excision of Malignant Lesion — Complicated D7440 — Excision of Malignant Tumor — Lesion ≤ 1.25 cm D7441 — Excision of Malignant Tumor — Lesion > 1.25 cm D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7460 — Removal of Benign Non-Odontogenic Cyst ≤ 1.25 cm D7461 — Removal of Benign Non-Odontogenic Cyst > 1.25 cm D7465 — Destruction of Lesion (Physical/Chemical Method) D7471 — Removal of Lateral Exostosis D7472 — Removal of Torus Palatinus D7473 — Removal of Torus Mandibularis D7485 — Reduction of Osseous Tuberosity D7490 — Radical Resection of Mandible D7509 — Marsupialization of Cyst D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7521 — Incision and Drainage — Extraoral (Soft Tissue, Complicated) D7530 — Removal of Foreign Body — Skin/Areolar Tissue D7540 — Removal of Reaction-Producing Foreign Body (Musculoskeletal) D7550 — Partial Ostectomy/Sequestrectomy D7560 — Maxillary Sinusotomy for Removal of Tooth Fragment D7610 — Maxilla — Open Reduction (Teeth Immobilized) D7620 — Maxilla — Closed Reduction (Teeth Immobilized) D7630 — Mandible — Open Reduction (Teeth Immobilized) D7640 — Mandible — Closed Reduction (Teeth Immobilized) D7650 — Malar and/or Zygomatic Arch — Open Reduction D7660 — Malar and/or Zygomatic Arch — Closed Reduction D7670 — Alveolus — Closed Reduction/Stabilization D7671 — Alveolus — Open Reduction/Stabilization D7680 — Facial Bones — Complicated Reduction D7710 — Maxilla — Open Reduction (No Interdental Fixation) D7720 — Maxilla — Closed Reduction (No Interdental Fixation) D7730 — Mandible — Open Reduction (No Interdental Fixation) D7740 — Mandible — Closed Reduction (No Interdental Fixation) D7750 — Malar/Zygomatic — Open (No Interdental Fixation) D7760 — Malar/Zygomatic — Closed (No Interdental Fixation) D7770 — Alveolus — Open Reduction/Stabilization D7771 — Alveolus — Closed Reduction/Stabilization D7780 — Facial Bones — Complicated (No Interdental Fixation) D7810 — Open Reduction of Dislocation D7820 — Closed Reduction of Dislocation D7830 — Manipulation Under Anesthesia D7840 — Condylectomy D7850 — Surgical Discectomy (w/ or w/o Implant) D7852 — Disc Repair D7854 — Synovectomy D7856 — Myotomy D7858 — Joint Reconstruction D7860 — Arthrotomy D7865 — Arthroplasty D7870 — Arthrocentesis D7871 — Non-Arthroscopic Lysis/Lavage of TMJ D7872 — Arthroscopy — Diagnostic (No Surgical Intervention) D7873 — Arthroscopy — Surgical: Lavage/Lysis D7874 — Arthroscopy — Surgical: Disc Repositioning/Repair D7875 — Arthroscopy — Surgical: Synovectomy D7876 — Arthroscopy — Surgical: Discectomy D7877 — Arthroscopy — Surgical: Debridement D7880 — Occlusal Orthotic Device — By Report D7881 — Occlusal Orthotic Device — Adjustment D7899 — Unspecified TMD Therapy, By Report D7910 — Suture of Wound (Up to 5 cm) D7911 — Complicated Suture (Up to 5 cm) D7912 — Complicated Suture (> 5 cm) D7920 — Skin Graft D7921 — Collection/Application of Autologous Blood Concentrate D7922 — Placement of Intra-Socket Biological Dressing D7939 — Unspecified Surgical Procedure, By Report D7940 — Osteoplasty — Jaw Recontouring D7941 — Osteotomy — Mandibular Rami D7943 — Osteotomy — Mandibular Rami (w/ Bone Graft) D7944 — Osteotomy — Segmented/Subapical D7945 — Osteotomy — Body of Mandible D7946 — LeFort I — Maxilla (Sectioned) D7947 — LeFort I — Maxilla (Total) D7948 — LeFort II/III — Midface Osteotomy D7949 — LeFort II/III — With Bone Grafts D7950 — Osseous/Osteoperiosteal Graft — Mandible/Maxilla D7951 — Sinus Augmentation with Bone Graft D7952 — Sinus Augmentation via Lateral Open Approach D7953 — Bone Replacement Graft — Ridge Preservation D7955 — Repair of Maxillofacial Soft/Hard Tissue Defect D7956 — Guided Bone Regeneration — Edentulous Area D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7961 — Buccal/Labial Frenectomy D7962 — Lingual Frenectomy D7963 — Frenuloplasty D7970 — Excision of Hyperplastic Tissue — Per Arch D7971 — Excision of Pericoronal Gingiva D7972 — Surgical Reduction of Fibrous Tuberosity D7979 — Unspecified Surgical Procedure, By Report D7980 — Surgical Sialolithotomy D7981 — Excision of Salivary Gland D7982 — Sialodochoplasty D7983 — Closure of Salivary Fistula D7990 — Emergency Tracheotomy D7991 — Coronoidectomy D7993 — D7993 D7994 — Surgical Placement — Bone-Fixation Plate D7995 — Synthetic Graft — Mandible or Facial Bones D7996 — Implant — Mandible for Augmentation (Alloplastic) D7997 — Appliance Removal D7998 — Intraoral Placement of Fixation Device D7999 — Unspecified Oral Surgery Procedure, By Report

D8000 — D8000 D8010 — Limited Orthodontic — Primary Dentition D8020 — Limited Orthodontic — Transitional Dentition D8030 — Limited Orthodontic — Adolescent Dentition D8040 — Limited Orthodontic — Adult Dentition D8050 — D8050 D8060 — D8060 D8070 — Comprehensive Orthodontic — Transitional Dentition D8080 — Comprehensive Orthodontic — Adolescent Dentition D8090 — Comprehensive Orthodontic — Adult Dentition D8091 — Comprehensive Orthodontic — By Report D8099 — D8099 D8210 — Removable Appliance Therapy D8220 — Fixed Appliance Therapy D8660 — Pre-Orthodontic Treatment Exam D8670 — Periodic Orthodontic Treatment Visit D8671 — Periodic Orthodontic Treatment Visit (As Part of Contract) D8680 — Orthodontic Retention — Removable Appliance D8681 — Orthodontic Retention — Fixed Appliance D8695 — Removal of Fixed Orthodontic Appliances D8696 — Repair of Orthodontic Appliance D8697 — Re-cement/Re-bond Fixed Retainer (Maxillary) D8698 — Re-cement/Re-bond Fixed Retainer (Mandibular) D8699 — Re-cement/Re-bond Fixed Retainer, By Report D8701 — Repair of Fixed Retainer (Includes Re-attachment) D8702 — Replacement of Lost/Broken Retainer (Removable) D8703 — Replacement of Lost/Broken Retainer (Fixed) D8704 — Replacement of Lost/Broken Retainer, By Report D8999 — D8999

D9110 — Palliative (Emergency) Treatment D9120 — Fixed Partial Denture Sectioning D9128 — Metal-Based Temporization/Splinting (Single Tooth) D9129 — Metal-Based Temporization/Splinting (Each Additional) D9130 — Temporomandibular Joint Dysfunction — Non-Invasive D9210 — Local Anesthesia (Not w/ Procedure) D9211 — Regional Block Anesthesia D9212 — Trigeminal Division Block Anesthesia D9215 — Local Anesthesia (In Conjunction w/ Procedure) D9219 — Evaluation for Moderate Sedation D9222 — Deep Sedation/General Anesthesia — First 15 min D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9225 — Deep Sedation/General Anesthesia — Each Add'l 15 min (Dentist) D9230 — Inhalation Analgesia (Nitrous Oxide) D9239 — Intravenous Moderate Sedation — First 15 min D9241 — D9241 D9243 — Intravenous Moderate Sedation — Each Add'l 15 min D9244 — Non-IV Moderate Conscious Sedation (By Non-Treating Dentist) D9245 — Non-IV Moderate Conscious Sedation — First 15 min D9246 — Non-IV Moderate Conscious Sedation — Each Add'l 15 min D9247 — Non-IV Moderate Conscious Sedation — Supplemental D9248 — D9248 D9310 — Consultation — Specialist/Dentist D9311 — Consultation — With Another Dentist/Physician D9410 — House/Extended Care Facility Call D9420 — Hospital or ASC Call D9430 — Office Visit for Observation (No Services) D9440 — Office Visit — After Regular Hours D9450 — Case Presentation — Treatment Plan D9610 — Therapeutic Parenteral Drug — Single Admin D9612 — Therapeutic Parenteral Drug — Two+ Administrations D9613 — Infiltration of Sustained-Release Therapeutic Drug D9630 — Drugs or Medicaments (Not Otherwise Classified) D9910 — Application of Desensitizing Medicament D9911 — Application of Desensitizing Resin D9912 — Pre-Visit Patient Screening D9913 — D9913 D9914 — D9914 D9920 — Behavior Management — By Report D9930 — Treatment of Complications (Post-Surgical) D9932 — Cleaning/Inspection of Removable Appliance D9933 — Cleaning/Inspection of Fixed Appliance D9934 — Re-cement/Re-bond Fixed Retainer D9935 — Device Repair, By Report D9936 — Replacement Device/Appliance — Obstructive Sleep Apnea D9938 — Adjustment of Appliance (Obstructive Sleep Apnea) D9939 — D9939 D9941 — Fabrication of Athletic Mouthguard D9942 — Repair/Reline of Occlusal Guard D9943 — Occlusal Guard — By Report D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9945 — Occlusal Guard — Soft Appliance (Full Arch) D9946 — Occlusal Guard — Hard Appliance (Partial Arch) D9947 — Custom Sleep Apnea Appliance Fabrication/Delivery D9948 — D9948 D9949 — D9949 D9950 — Occlusion Analysis — Mounted Case D9951 — Occlusal Adjustment — Limited D9952 — Occlusal Adjustment — Complete D9953 — D9953 D9954 — D9954 D9955 — D9955 D9956 — D9956 D9957 — Repair/Reactivation of Sleep Apnea Appliance D9959 — Sleep Apnea Appliance — Custom, By Report D9961 — Duplicate/Copy of Patient Records D9970 — Enamel Microabrasion D9971 — Odontoplasty — 1–2 Teeth D9972 — External Bleaching — Per Arch D9973 — External Bleaching — Per Tooth D9974 — Internal Bleaching — Per Tooth D9975 — External Bleaching (Home Application, Per Arch) D9985 — D9985 D9986 — Missed Appointment D9987 — Cancelled Appointment D9990 — D9990 D9991 — Dental Case Management — Motivational Interviewing D9992 — Dental Case Management — Care Coordination D9993 — Dental Case Management — Access Coordination D9994 — Dental Case Management — Patient Education D9995 — Teledentistry — Synchronous (Real-Time) D9996 — Teledentistry — Asynchronous (Store-and-Forward) D9997 — Dental Case Management, By Report D9999 — Unspecified Adjunctive Procedure, By Report