Dental Reimbursement Rates in Indiana

D0310 — Sialography D0350 — Oral/Facial Photographic Images D0171 — Re-evaluation — Post-Operative D0330 — Panoramic X-Ray D0418 — Analysis of Saliva Specimen D0140 — Limited Oral Evaluation — Problem Focused D0191 — Assessment of a Patient D0321 — Other TMJ Films D0340 — 2D Cephalometric X-Ray D0602 — Caries Risk Assessment — Moderate Risk D0210 — Full Mouth X-Rays D0320 — TMJ Arthrogram D0425 — Caries Susceptibility Test D0426 — Caries Risk Assessment & Documentation (Low Risk) D0475 — Decalcification Procedure D0145 — Oral Evaluation for Patient Under 3 D0180 — Comprehensive Periodontal Evaluation D0190 — Screening of a Patient D0240 — Occlusal X-Ray D0251 — Extraoral — Posterior Dental X-Ray D0322 — Tomographic Survey D0472 — Accession of Tissue (Gross Exam Only) D0600 — Non-Ionizing Diagnostic Procedure D0801 — 3D Surface Scan — Pre-Ortho D0160 — Detailed/Extensive Oral Evaluation D0220 — Periapical X-Ray — First Film D0372 — Cone Beam CT — 3D Data Capture (Both Jaws) D0381 — Cone Beam CT — Other Capture D0394 — Digital Subtraction of Two Radiographs D0415 — Collection of Microbial Culture Specimen D0431 — Adjunctive Pre-Diagnostic Test (No Biopsy) D0461 — Pulp Vitality Test — Multiple Teeth D0470 — Diagnostic Cast D0502 — Other Oral Pathology Procedure D0601 — Caries Risk Assessment — Low Risk D0603 — Caries Risk Assessment — High Risk D0702 — 2D Cephalometric Radiographic Image D0703 — 2D Oral/Facial Photographic Image D0706 — Intraoral — Occlusal Radiographic Image

D1575 — Distal Shoe Space Maintainer D1351 — Dental Sealant — Per Tooth D1120 — Child Prophylaxis D1355 — Caries Preventive Medicament Application D1310 — Nutritional Counseling for Dental Caries D1520 — Space Maintainer — Removable, Unilateral D1330 — Oral Hygiene Instructions D1516 — Space Maintainer — Fixed, Bilateral (Maxillary) D1353 — Sealant Repair — Per Tooth D1354 — Interim Caries Arresting Medicament (SDF) D1517 — Space Maintainer — Fixed, Bilateral (Mandibular) D1551 — Re-cement/Re-bond Space Maintainer (Unilateral) D1558 — Removal of Fixed Space Maintainer (Bilateral, Mand) D1301 — Panoramic Radiograph for Caries Risk D1320 — Tobacco Counseling for Oral Health D1510 — Space Maintainer — Fixed, Unilateral D1526 — Space Maintainer — Removable, Bilateral (Maxillary) D1527 — Space Maintainer — Removable, Bilateral (Mandibular) 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)

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

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

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

D5878 — Add Wrought Wire Clasp (Tooth-Supported) D5611 — Repair Resin Partial Denture Base (Upper) D5810 — Interim Complete Upper Denture D5228 — Immediate Lower Partial Denture — Flexible Base D5670 — Replace Teeth & Acrylic on Metal Framework D5731 — Reline Complete Lower Denture (Chair-side) D5820 — Interim Partial Upper Denture D5225 — Upper Partial Denture — Flexible Base D5212 — Lower Partial Denture — Resin Base (w/ Clasps/Rests) D5612 — Repair Resin Partial Denture Base (Lower) D5410 — Adjust Complete Upper Denture D5866 — Overdenture — Partial (Implant Supported) D5214 — Lower Partial Denture — Cast Metal Framework D5730 — Reline Complete Upper Denture (Chair-side) D5862 — Precision Attachment — By Report D5864 — Overdenture — Partial (Implant/Root Supported) D5875 — Modification of Removable Prosthesis (Implant) D5512 — Repair Broken Complete Denture Base (Lower) D5711 — Rebase Complete Lower Denture D5140 — Immediate Lower Denture D5283 — Removable Unilateral Partial Denture — 1 Piece (Resin) D5286 — Removable Unilateral Partial Denture — 2 Piece (Metal) D5640 — Replace Broken Teeth — Per Tooth D5765 — Soft Liner for Complete or Partial Denture D5821 — Interim Partial Lower Denture D5750 — Reline Complete Upper Denture (Lab) D5110 — Complete Upper Denture D5130 — Immediate Upper Denture D5213 — Upper Partial Denture — Cast Metal Framework D5226 — Lower Partial Denture — Flexible Base D5282 — Removable Unilateral Partial Denture — 1 Piece (Metal) D5621 — Repair Cast Partial Framework (Upper) D5811 — Interim Complete Lower Denture D5120 — Complete Lower Denture D5221 — Immediate Upper Partial Denture — Resin Base D5222 — Immediate Lower Partial Denture — Resin Base D5411 — Adjust Complete Lower Denture D5740 — Reline Upper Partial Denture (Chair-side) D5741 — Reline Lower Partial Denture (Chair-side) D5751 — Reline Complete Lower Denture (Lab) D5865 — Overdenture — Complete (Implant Supported) D5877 — Replacement of Locator Male, By Report D5211 — Upper Partial Denture — Resin Base (w/ Clasps/Rests) D5223 — Immediate Upper Partial Denture — Cast Metal D5224 — Immediate Lower Partial Denture — Cast Metal D5227 — Immediate Upper Partial Denture — Flexible Base D5284 — Removable Unilateral Partial Denture — 1 Piece (Flex) D5622 — Repair Cast Partial Framework (Lower) D5630 — Repair or Replace Broken Clasp — Per Tooth D5660 — Add Clasp to Existing Partial Denture D5671 — Replace All Teeth & Acrylic on Cast Metal Framework D5720 — Rebase Upper Partial Denture D5760 — Reline Upper Partial Denture (Lab) D5863 — Overdenture — Complete (Implant/Root Supported) D5867 — Replacement of Attachment — Implant Overdenture D5982 — Surgical Stent D5986 — Fluoride Gel Carrier D5988 — Surgical Splint D5422 — Adjust Partial Lower Denture D5520 — Replace Missing/Broken Teeth — Complete Denture D5721 — Rebase Lower Partial Denture D5725 — Rebase Hybrid Prosthesis D5761 — Reline Lower Partial Denture (Lab) D5850 — Tissue Conditioning (Upper) D5421 — Adjust Partial Upper Denture D5650 — Add Tooth to Existing Partial Denture D5710 — Rebase Complete Upper Denture

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

D7291 — Transseptal Fiberotomy D7473 — Removal of Torus Mandibularis D7956 — Guided Bone Regeneration — Edentulous Area D7520 — Incision and Drainage — Extraoral (Soft Tissue) D7350 — Vestibuloplasty — Ridge Extension (w/ Graft) D7240 — Extraction — Completely Bony Impacted Tooth D7950 — Osseous/Osteoperiosteal Graft — Mandible/Maxilla D7961 — Buccal/Labial Frenectomy D7282 — Mobilization of Erupted/Malpositioned Tooth D7272 — Tooth Transplantation D7465 — Destruction of Lesion (Physical/Chemical Method) D7280 — Surgical Exposure of Impacted Tooth (Orthodontic) D7320 — Alveoloplasty — Without Extractions (Per Quad) D7509 — Marsupialization of Cyst D7962 — Lingual Frenectomy D7220 — Extraction — Soft Tissue Impacted Tooth D7261 — Primary Closure of Sinus Perforation D7284 — Excisional Biopsy — Bone D7296 — Corticotomy — One to Three Tooth Spaces D7340 — Vestibuloplasty — Ridge Extension D7450 — Removal of Benign Odontogenic Cyst ≤ 1.25 cm D7953 — Bone Replacement Graft — Ridge Preservation D7972 — Surgical Reduction of Fibrous Tuberosity D7994 — Surgical Placement — Bone-Fixation Plate D7287 — Exfoliative Cytological Sample Collection D7297 — Corticotomy — Four or More Tooth Spaces D7460 — Removal of Benign Non-Odontogenic Cyst ≤ 1.25 cm D7471 — Removal of Lateral Exostosis D7510 — Incision and Drainage — Intraoral (Soft Tissue) D7111 — Extraction — Coronal Remnants (Primary Tooth) D7260 — Oroantral Fistula Closure D7285 — Incisional Biopsy — Oral Tissue (Hard) D7286 — Incisional Biopsy — Oral Tissue (Soft) D7288 — Brush Biopsy — Transepithelial Sample Collection D7290 — Surgical Repositioning of Teeth D7310 — Alveoloplasty — With Extractions (Per Quad) D7321 — Alveoloplasty — Without Extractions (1–3 Teeth) D7451 — Removal of Benign Odontogenic Cyst > 1.25 cm D7461 — Removal of Benign Non-Odontogenic Cyst > 1.25 cm D7472 — Removal of Torus Palatinus D7881 — Occlusal Orthotic Device — Adjustment D7921 — Collection/Application of Autologous Blood Concentrate D7939 — Unspecified Surgical Procedure, By Report D7957 — Guided Bone Regeneration — Non-Resorbable Membrane D7250 — Extraction — Residual Root Removal D7485 — Reduction of Osseous Tuberosity D7550 — Partial Ostectomy/Sequestrectomy D7140 — Extraction — Erupted Tooth or Exposed Root D7210 — Extraction — Surgical (Erupted Tooth) D7230 — Extraction — Partially Bony Impacted Tooth D7241 — Extraction — Completely Bony Impacted (Complicated) D7410 — Excision of Benign Lesion ≤ 1.25 cm D7411 — Excision of Benign Lesion > 1.25 cm D7511 — Incision and Drainage — Intraoral (Soft Tissue, Complicated) D7820 — Closed Reduction of Dislocation D7963 — Frenuloplasty D7252 — Tooth Removal of Impacted Tooth (Soft Tissue) D7270 — Tooth Reimplantation/Stabilization D7283 — Placement of Device for Eruption of Impacted Tooth D7311 — Alveoloplasty — With Extractions (1–3 Teeth) D7970 — Excision of Hyperplastic Tissue — Per Arch D7971 — Excision of Pericoronal Gingiva D7251 — Coronectomy — Intentional Partial Tooth Removal D7521 — Incision and Drainage — Extraoral (Soft Tissue, Complicated) D7530 — Removal of Foreign Body — Skin/Areolar Tissue D7880 — Occlusal Orthotic Device — By Report D7910 — Suture of Wound (Up to 5 cm) D7922 — Placement of Intra-Socket Biological Dressing D7949 — LeFort II/III — With Bone Grafts

D8080 — Comprehensive Orthodontic — Adolescent Dentition D8699 — Re-cement/Re-bond Fixed Retainer, By Report D8680 — Orthodontic Retention — Removable Appliance D8070 — Comprehensive Orthodontic — Transitional Dentition D8090 — Comprehensive Orthodontic — Adult Dentition D8091 — Comprehensive Orthodontic — By Report D8660 — Pre-Orthodontic Treatment Exam D8670 — Periodic Orthodontic Treatment Visit D8671 — Periodic Orthodontic Treatment Visit (As Part of Contract) 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) D8701 — Repair of Fixed Retainer (Includes Re-attachment) D8702 — Replacement of Lost/Broken Retainer (Removable)

D9938 — Adjustment of Appliance (Obstructive Sleep Apnea) D9941 — Fabrication of Athletic Mouthguard D9612 — Therapeutic Parenteral Drug — Two+ Administrations D9952 — Occlusal Adjustment — Complete D9420 — Hospital or ASC Call D9110 — Palliative (Emergency) Treatment D9223 — Deep Sedation/General Anesthesia — Each Add'l 15 min D9239 — Intravenous Moderate Sedation — First 15 min D9215 — Local Anesthesia (In Conjunction w/ Procedure) D9222 — Deep Sedation/General Anesthesia — First 15 min D9942 — Repair/Reline of Occlusal Guard D9974 — Internal Bleaching — Per Tooth D9130 — Temporomandibular Joint Dysfunction — Non-Invasive D9224 — Deep Sedation/General Anesthesia — First 15 min (Dentist) D9246 — Non-IV Moderate Conscious Sedation — Each Add'l 15 min D9944 — Occlusal Guard — Hard Appliance (Full Arch) D9945 — Occlusal Guard — Soft Appliance (Full Arch) D9972 — External Bleaching — Per Arch D9994 — Dental Case Management — Patient Education D9410 — House/Extended Care Facility Call D9430 — Office Visit for Observation (No Services) D9450 — Case Presentation — Treatment Plan D9970 — Enamel Microabrasion D9930 — Treatment of Complications (Post-Surgical) D9212 — Trigeminal Division Block Anesthesia D9225 — Deep Sedation/General Anesthesia — Each Add'l 15 min (Dentist) D9243 — Intravenous Moderate Sedation — Each Add'l 15 min D9310 — Consultation — Specialist/Dentist D9311 — Consultation — With Another Dentist/Physician D9610 — Therapeutic Parenteral Drug — Single Admin D9947 — Custom Sleep Apnea Appliance Fabrication/Delivery D9951 — Occlusal Adjustment — Limited D9971 — Odontoplasty — 1–2 Teeth D9219 — Evaluation for Moderate Sedation D9920 — Behavior Management — By Report D9946 — Occlusal Guard — Hard Appliance (Partial Arch) D9128 — Metal-Based Temporization/Splinting (Single Tooth) D9211 — Regional Block Anesthesia D9244 — Non-IV Moderate Conscious Sedation (By Non-Treating Dentist) D9247 — Non-IV Moderate Conscious Sedation — Supplemental D9440 — Office Visit — After Regular Hours D9613 — Infiltration of Sustained-Release Therapeutic Drug D9630 — Drugs or Medicaments (Not Otherwise Classified) D9933 — Cleaning/Inspection of Fixed Appliance D9950 — Occlusion Analysis — Mounted Case D9973 — External Bleaching — Per Tooth