Group CLINICAL ORAL EVALUATIONS

periodic oral evaluation - established 200

D0120
patient
limited oral evaluation - problem 250
D0140
focused
oral evaluation for a patient under 250
D0145 three years of age and counseling
with primary caregiver
comprehensive oral evaluation - new 250
D0150
or established patient
detailed and extensive oral 250
D0160 evaluation - problem focused, by
report
re-evaluation - limited, problem 200
D0170 focused (established patient; not
post-operative visit)

RADIOGRAPHS/DIAGNOSTIC IMAGING
Group
(INCLUDING INTERPRETATION)

intraoral - complete series (including 650

D0210
bitewings)

D0220 intraoral - periapical first film 200

intraoral - periapical each additional 100

D0230
film

D0270 bitewing - single film 200

D0272 bitewings - two films 250

D0273 bitewings - three films 300

D0274 bitewings - four films 350

D0277 vertical bitewings - 7 to 8 films 550

D0350 oral/facial photographic images 150

Group TESTS AND EXAMINATIONS

D0460 pulp vitality tests 140

D0470 diagnostic casts 300

Group DENTAL PROPHYLAXIS

D1110 prophylaxis - adult 700

D1120 prophylaxis - child 600

Group OTHER PREVENTIVE SERVICES

nutritional counseling for control of 200

D1310
dental disease
tobacco counseling for the control 200
D1320
and prevention of oral disease

D1330 oral hygiene instructions 200

D1351 sealant - per tooth 200

preventive resin restoration in a 250

D1352 moderate to high caries risk patient
permanent tooth

SPACE MAINTENANCE (PASSIVE

Group
APPLIANCES)

D1510 space maintainer - fixed - unilateral 1200

D1515 space maintainer - fixed - bilateral 2000

space maintainer - removable - 1200

D1520
unilateral
space maintainer - removable - 2000
D1525
bilateral

D1550 re-cementation of space maintainer 250

D1555 removal of fixed space maintainer 250

AMALGAM RESTORATIONS
Group
(INCLUDING POLISHING)

amalgam - one surface, primary or 450

D2140
permanent
amalgam - two surfaces, primary or 500
D2150
permanent
amalgam - three surfaces, primary 550
D2160
or permanent
amalgam - four or more surfaces, 650
D2161
primary or permanent
 RESIN-BASED COMPOSITE
Group
RESTORATIONS - DIRECT

resin-based composite - one surface, 700

D2330
anterior
resin-based composite - two 750
D2331
surfaces, anterior
resin-based composite - three 800
D2332
surfaces, anterior
resin-based composite - four or more 850
D2335 surfaces or involving incisal angle
(anterior)
resin-based composite crown, 900
D2390
anterior
resin-based composite - one surface, 700
D2391
posterior
resin-based composite - two 750
D2392
surfaces, posterior
resin-based composite - three 800
D2393
surfaces, posterior
resin-based composite - four or more 850
D2394
surfaces, posterior

Group INLAY/ONLAY RESTORATIONS

D2510 inlay - metallic - one surface

D2520 inlay - metallic - two surfaces

inlay - metallic - three or more

D2530
surfaces

D2542 onlay - metallic-two surfaces

D2543 onlay - metallic-three surfaces

onlay - metallic-four or more

D2544
surfaces

Porcelain/ceramic inlays/onlays
Group include all indirect ceramic and
porcelain type inlays/onlays.

inlay - porcelain/ceramic - one

D2610
surface

inlay - porcelain/ceramic - two

D2620
surfaces

inlay - porcelain/ceramic - three or

D2630
more surfaces

onlay - porcelain/ceramic - two

D2642
surfaces
 onlay - porcelain/ceramic - three
D2643
surfaces

onlay - porcelain/ceramic - four or

D2644
more surfaces

Resin-based composite inlays/onlays

Group
must utilize indirect technique.

inlay - resin-based composite - one

D2650
surface

inlay - resin-based composite - two

D2651
surfaces

inlay - resin-based composite - three

D2652
or more surfaces

onlay - resin-based composite - two

D2662
surfaces

onlay - resin-based composite - three

D2663
surfaces

onlay - resin-based composite - four

D2664
or more surfaces
 CROWNS - SINGLE RESTORATIONS
Group
ONLY

crown - resin-based composite

D2710
(indirect)

crown - resin-based composite

D2712
(indirect)

D2720 crown - resin with high noble metal

crown - resin with predominantly

D2721
base metal

D2722 crown - resin with noble metal

D2740 crown - porcelain/ceramic substrate

crown - porcelain fused to high noble

D2750
metal

crown - porcelain fused to

D2751
predominantly base metal

crown - porcelain fused to noble

D2752
metal

D2780 crown - 3/4 cast high noble metal

 crown - 3/4 cast predominantly base
D2781
metal

D2782 crown - 3/4 cast noble metal

D2783 crown - 3/4 porcelain/ceramic

D2790 crown - full cast high noble metal

crown - full cast predominantly base

D2791
metal

D2792 crown - full cast noble metal

D2794 crown - titanium

D2799 provisional crown 300

Group OTHER RESTORATIVE SERVICES

recement inlay, onlay, or partial 400

D2910
coverage restoration
recement cast or prefabricated post 350
D2915
and core

D2920 recement crown 350

D2930 prefabricated stainless steel crown - 850

 primary tooth
prefabricated stainless steel crown - 850
D2931
permanent tooth

D2932 prefabricated resin crown 600

prefabricated stainless steel crown

D2933
with resin window

prefabricated esthetic coated 950

D2934
stainless steel crown - primary tooth

D2940 protective restoration 800

D2950 core buildup, including any pins 600

pin retention - per tooth, in addition

D2951
to restoration

post and core in addition to crown, 900

D2952
indirectly fabricated
each additional indirectly fabricated 800
D2953
post - same tooth
prefabricated post and core in 800
D2954
addition to crown
post removal (not in conjunction with 600
D2955
endodontic therapy)
each additional prefabricated post - 700
D2957
same tooth
labial veneer (resin laminate) - 900
D2960
chairside
labial veneer (resin laminate) - 2000
D2961
laboratory

D2970 temporary crown (fractured tooth) 450

additional procedures to construct

D2971 new crown under existing partial
denture framework
D2975 coping

D2980 crown repair, by report 400

unspecified restorative procedure,

D2999
by report

Group PULP CAPPING

pulp cap - direct (excluding final 200

D3110
restoration)
pulp cap - indirect (excluding final 200
D3120
restoration)

Group PULPOTOMY

therapeutic pulpotomy (excluding 600

final restoration) - removal of pulp
D3220 coronal to the dentinocemental
junction and application of
medicament
pulpal debridement, primary and 600
D3221
permanent teeth
partial pulpotomy for apexogenesis - 600
D3222 permanent tooth with incomplete
root development
 ENDODONTIC THERAPY ON PRIMARY
Group
TEETH

pulpal therapy (resorbable filling) - 650

D3230 anterior, primary tooth (excluding
final restoration)
pulpal therapy (resorbable filling) - 750
D3240 posterior, primary tooth (excluding
final restoration)

ENDODONTIC THERAPY (INCLUDING

TREATMENT PLAN, CLINICAL
Group
PROCEDURES AND FOLLOW-UP
CARE)
endodontic therapy, anterior tooth 1200
D3310
(excluding final restoration)
endodontic therapy, bicuspid tooth 1400
D3320
(excluding final restoration)
endodontic therapy, molar 1600
D3330
(excluding final restoration)
treatment of root canal obstruction; 1800
D3331
non-surgical access
incomplete endodontic therapy; 750
D3332 inoperable, unrestorable or fractured
tooth
internal root repair of perforation 2100
D3333
defects
Group ENDODONTIC RETREATMENT

retreatment of previous root canal 2000

D3346
therapy - anterior
retreatment of previous root canal 2200
D3347
therapy - bicuspid
retreatment of previous root canal 2400
D3348
therapy - molar

APEXIFICATION/RECALCIFICATION
Group AND PULPAL REGENERATION
PROCEDURES

apexification/recalcification/pulpal 600
regeneration initial visit (apical
D3351 closure/calcific repair of perforations,
root resorption, pulp space
disinfection, etc.)
apexification/recalcification/pulpal 200
regeneration - interim medication
replacement (apical closure/calcific
D3352
repair of perforations, root
resorption, pulp space disinfection,
etc.)
apexification/recalcification - final 1200
visit (includes completed root canal
D3353 therapy - apical closure/calcific
repair of perforations, root
resorption, etc.)
pulpal regeneration (completion of 1600
regenerative treatment in an
D3354 immature permanent tooth with a
necrotic pulp); does not include final
restoration
 APICOECTOMY/PERIRADICULAR
Group
SERVICES

D3450 root amputation - per root

intentional reimplantation (including

D3470
necessary splinting)

Group OTHER ENDODONTIC PROCEDURES

surgical procedure for isolation of 120

D3910
tooth with rubber dam
hemisection (including any root 650
D3920 removal), not including root canal
therapy
canal preparation and fitting of 550
D3950
preformed dowel or post

SURGICAL SERVICES (INCLUDING

Group
USUAL POSTOPERATIVE CARE)

gingivectomy or gingivoplasty - four 800

D4210 or more contiguous teeth or tooth
bounded spaces per quadrant
 gingivectomy or gingivoplasty - one 700
D4211 to three contiguous teeth or tooth
bounded spaces per quadrant

anatomical crown exposure - four or

D4230
more contiguous teeth per quadrant

anatomical crown exposure - one to

D4231
three teeth per quadrant

gingival flap procedure, including

root planing - four or more
D4240
contiguous teeth or tooth bounded
spaces per quadrant
gingival flap procedure, including
root planing - one to three
D4241
contiguous teeth or tooth bounded
spaces per quadrant

D4245 apically positioned flap

clinical crown lengthening - hard

D4249
tissue

osseous surgery (including flap entry

and closure) - four or more
D4260
contiguous teeth or tooth bounded
spaces per quadrant
osseous surgery (including flap entry
and closure) - one to three
D4261
contiguous teeth or tooth bounded
spaces per quadrant

surgical revision procedure, per

D4268
tooth
 NON-SURGICAL PERIODONTAL
Group
SERVICE

D4320 provisional splinting - intracoronal

D4321 provisional splinting - extracoronal

periodontal scaling and root planing 650

D4341
- four or more teeth per quadrant
periodontal scaling and root planing 650
D4342
- one to three teeth per quadrant
full mouth debridement to enable 650
D4355 comprehensive evaluation and
diagnosis
localized delivery of antimicrobial 150
agents via a controlled release
D4381
vehicle into diseased crevicular
tissue, per tooth, by report

Group OTHER PERIODONTAL SERVICES

D4910 periodontal maintenance

unscheduled dressing change (by 350

D4920
someone other than treating dentist)
 unspecified periodontal procedure,
D4999
by report

COMPLETE DENTURES (INCLUDING

Group
ROUTINE POST-DELIVERY CARE)

D5110 complete denture - maxillary 2700

D5120 complete denture - mandibular 2700

D5130 immediate denture - maxillary

D5140 immediate denture - mandibular

PARTIAL DENTURES (INCLUDING

Group
ROUTINE POST-DELIVERY CARE)

maxillary partial denture - resin base

D5211 (including any conventional clasps,
rests and teeth)

mandibular partial denture - resin

D5212 base (including any conventional
clasps, rests and teeth)

maxillary partial denture - cast metal

framework with resin denture bases
D5213
(including any conventional clasps,
rests and teeth)
 mandibular partial denture - cast
metal framework with resin denture
D5214
bases (including any conventional
clasps, rests and teeth)

maxillary partial denture - flexible

D5225 base (including any clasps, rests and
teeth)

mandibular partial denture - flexible

D5226 base (including any clasps, rests and
teeth)

removable unilateral partial denture

D5281 - one piece cast metal (including
clasps and teeth

Group ADJUSTMENTS TO DENTURES

D5410 adjust complete denture - maxillary

adjust complete denture -

D5411
mandibular

D5421 adjust partial denture - maxillary

D5422 adjust partial denture - mandibular

Group REPAIRS TO COMPLETE DENTURES

D5510 repair broken complete denture base

replace missing or broken teeth -

D5520
complete denture (each tooth)

Group REPAIRS TO PARTIAL DENTURES

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

 replace all teeth and acrylic on cast
D5670
metal framework (maxillary)

replace all teeth and acrylic on cast

D5671
metal framework (mandibular)

Group DENTURE REBASE PROCEDURES

D5710 rebase complete maxillary denture

D5711 rebase complete mandibular denture

D5720 rebase maxillary partial denture

D5721 rebase mandibular partial denture

Group DENTURE RELINE PROCEDURES

reline complete maxillary denture

D5730
(chairside)
 reline complete mandibular denture
D5731
(chairside)

reline maxillary partial denture

D5740
(chairside)

reline mandibular partial denture

D5741
(chairside)

reline complete maxillary denture

D5750
(laboratory)

reline complete mandibular denture

D5751
(laboratory)

reline maxillary partial denture

D5760
(laboratory)

reline mandibular partial denture

D5761
(laboratory)

Group INTERIM PROSTHESIS

D5810 interim complete denture (maxillary) 2500

interim complete denture 2500

D5811
(mandibular)

D5820 interim partial denture (maxillary) 650

D5821 interim partial denture (mandibular) 650

 OTHER REMOVABLE PROSTHETIC
Group
SERVICES

D5851 tissue conditioning, mandibular

D5860 overdenture - complete, by report 3500

D5861 overdenture - partial, by report 2500

D5862 precision attachment, by report 800

replacement of replaceable part of

semi-precision or precision
D5867
attachment (male or female
component)

D5986 fluoride gel carrier 900

D5988 surgical splint 1600

D5991 topical medicament carrier 900

adjust maxillofacial prosthetic

D5992
appliance, by report

maintenance and cleaning of a 700

maxillofacial prosthesis (extra or
D5993
intraoral) other than required
adjustments, by report
Group Single Crowns, Abutment Supported

abutment supported 1200

D6058
porcelain/ceramic crown
abutment supported porcelain fused 1300
D6059
to metal crown (high noble metal)

abutment supported porcelain fused

D6060 to metal crown (predominantly base
metal)

abutment supported porcelain fused

D6061
to metal crown (noble metal)

abutment supported cast metal

D6062
crown (high noble metal)

abutment supported cast metal 800

D6063
crown (predominantly base metal)
abutment supported cast metal 900
D6064
crown (noble metal)

FIXED PARTIAL DENTURE RETAINERS

Group
- CROWNS

pontic - indirect resin based

D6205
composite

D6210 pontic - cast high noble metal

pontic - cast predominantly base

D6211
metal
D6212 pontic - cast noble metal

D6214 pontic - titanium

pontic - porcelain fused to high noble

D6240
metal

pontic - porcelain fused to

D6241
predominantly base metal

pontic - porcelain fused to noble

D6242
metal

D6245 pontic - porcelain/ceramic

D6250 pontic - resin with high noble metal

pontic - resin with predominantly

D6251
base metal

D6252 pontic - resin with noble metal

D6253 provisional pontic

D6254 interim pontic

 retainer - cast metal for resin
D6545
bonded fixed prosthesis

retainer - porcelain/ceramic for resin

D6548
bonded fixed prosthesis

inlay - porcelain/ceramic, two

D6600
surfaces

inlay - porcelain/ceramic, three or

D6601
more surfaces

inlay - cast high noble metal, two

D6602
surfaces

inlay - cast high noble metal, three

D6603
or more surfaces

inlay - cast predominantly base

D6604
metal, two surfaces

inlay - cast predominantly base

D6605
metal, three or more surfaces

inlay - cast noble metal, two

D6606
surfaces

inlay - cast noble metal, three or

D6607
more surfaces

D6624 inlay - titanium

 onlay -porcelain/ceramic, two
D6608
surfaces

onlay - porcelain/ceramic, three or

D6609
more surfaces

onlay - cast high noble metal, two

D6610
surfaces

onlay - cast high noble metal, three

D6611
or more surfaces

onlay - cast predominantly base

D6612
metal, two surfaces

onlay - cast predominantly base

D6613
metal, three or more surfaces

onlay - cast noble metal, two

D6614
surfaces

onlay - cast noble metal, three or

D6615
more surfaces

D6634 onlay - titanium

crown - indirect resin based

D6710
composite

D6720 crown - resin with high noble metal

 crown - resin with predominantly
D6721
base metal

D6722 crown - resin with noble metal

D6740 crown - porcelain/ceramic

crown - porcelain fused to high noble

D6750
metal

crown - porcelain fused to

D6751
predominantly base metal

crown - porcelain fused to noble

D6752
metal

D6780 crown - 3/4 cast high noble metal

crown - 3/4 cast predominantly base

D6781
metal

D6782 crown - 3/4 cast noble metal

D6783 crown - 3/4 porcelain/ceramic

D6790 crown - full cast high noble metal

 crown - full cast predominantly base
D6791
metal

D6792 crown - full cast noble metal

D6794 crown - titanium

D6793 provisional retainer crown

D6795 interim retainer crown

D6920 connector bar

D6930 recement fixed partial denture 400

D6940 stress breaker

D6950 precision attachment

post and core in addition to fixed

D6970 partial denture retainer, indirectly
fabricated

prefabricated post and core in 450

D6972 addition to fixed partial denture
retainer

core build up for retainer, including

D6973
any pins
D6975 coping - metal

each additional indirectly fabricated

D6976
post - same tooth

each additional prefabricated post - 300

D6977
same tooth

D6980 fixed partial denture repair, by report 600

D6985 pediatric partial denture, fixed

unspecified fixed prosthodontic

D6999
procedure, by report

extraction, coronal remnants - 700

D7111
deciduous tooth
extraction, erupted tooth or exposed 1000
D7140 root (elevation and/or forceps
removal)
surgical removal of erupted tooth 1300
requiring removal of bone and/or
D7210 sectioning of tooth, and including
elevation of mucoperiosteal flap if
indicated
removal of impacted tooth - soft 1500
D7220
tissue
removal of impacted tooth - partially 1700
D7230
bony
removal of impacted tooth - 1850
D7240
completely bony
removal of impacted tooth - 2000
D7241 completely bony, with unusual
surgical complications
D7250 surgical removal of residual tooth 1700
 roots (cutting procedure)
coronectomy intentional partial 1250
D7251
tooth removal

D7260 oroantral fistula closure 400

primary closure of a sinus 300

D7261
perforation
tooth reimplantation and/or 1000
D7270 stabilization of accidentally evulsed
or displaced tooth
tooth transplantation (includes
reimplantation from one site to
D7272
another and splinting and/or
stabilization)
surgical access of an unerupted 700
D7280
tooth

mobilization of erupted or
D7282
malpositioned tooth to aid eruption

placement of device to facilitate

D7283
eruption of impacted tooth

alveoloplasty in conjunction with 1000

D7310 extractions four or more teeth or
tooth spaces, per quadrant
alveoloplasty in conjunction with 800
D7311 extractions - one to three teeth or
tooth spaces, per quadrant
alveoloplasty not in conjunction with 1200
D7320 extractions four or more teeth or
tooth spaces, per quadrant
alveoloplasty not in conjunction with 1000
D7321 extractions - one to three teeth or
tooth spaces, per quadrant
 incision and drainage of abscess - 650
D7510
intraoral soft tissue

suture of recent small wounds up to 300

D7910
5 cm

D8210 removable appliance therapy

D8220 fixed appliance therapy

palliative (emergency) treatment of 800

D9110
dental pain - minor procedure

D9120 fixed partial denture sectioning 500

local anesthesia not in conjunction 300

D9210
with operative or surgical procedures

D9211 regional block anesthesia 300

local anesthesia in conjunction with 200

D9215
operative or surgical procedures
 palliative (emergency) treatment of 600
D9110
dental pain - minor procedure
consultation - diagnostic service 300
provided by dentist or physician
D9310
other than requesting dentist or
physician

other drugs and/or medicaments, by

D9630
report

application of desensitizing 800

D9910
medicament
application of desensitizing resin for 250
D9911 cervical and/or root surface, per
tooth

D9920 behavior management, by report 250

treatment of complications (post-

D9930 surgical) - unusual circumstances, by
report

D9940 occlusal guard, by report 1800

D9941 fabrication of athletic mouthguard 1800

D9942 repair and/or reline of occlusal guard 800

D9950 occlusion analysis - mounted case 300

D9951 occlusal adjustment - limited 850

D9952 occlusal adjustment - complete 1700

D9970 enamel microabrasion 1700

 odontoplasty 1 - 2 teeth; includes 170
D9971
removal of enamel projections

D9972 external bleaching - per arch 1250

D9973 external bleaching - per tooth 250

D9974 internal bleaching - per tooth 600

unspecified adjunctive procedure, by

D9999
report