101 CMR, § 314.05
Code | Allowed Fee | Allowed Fee (EPSDT-eligible members) | Description |
I. Diagnostic | |||
D0120 | $24 | $31 | Periodic oral evaluation - established patient |
D0140 | $43 | $49 | Limited oral evaluation - problem focused |
D0145 | I.C. | $27 | Oral evaluation for a patient under three years old and counseling with primary caregiver |
D0150 | $41 | $62 | Comprehensive oral evaluation - new or established patient |
D0160 | $64 | $77 | Detailed and extensive oral evaluation - problem focused, by report |
D0170 | $39 | $45 | Re-evaluation - limited, problem focused (established patient; not postoperative visit) |
D0171 | I.C. | I.C. | Re-evaluation - post-operative office visit |
D0180 | $37 | $58 | Comprehensive periodontal evaluation - new or established patient |
D0190 | $20 | $29 | Screening of patient |
D0191 | $20 | $29 | Assessment of patient |
D0210 | $76 | $94 | Intraoral - complete series of radiographic images |
D0220 | $15 | $21 | Intraoral - periapical, first radiographic image |
D0230 | $13 | $17 | Intraoral - periapical, each additional radiographic image |
D0240 | $21 | $26 | Intraoral - occlusal radiographic image |
D0250 | $23 | $28 | Extra oral 2D projection radiographic image created using a stationary radiation source, and detector |
D0251 | I.C. | I.C. | Extra-oral posterior dental radiographic image |
D0270 | $14 | $17 | Bitewing - single radiographic image |
D0272 | $25 | $32 | Bitewings - two radiographic images |
D0273 | $27 | $35 | Bitewings - three radiographic images |
D0274 | $36 | $46 | Bitewings - four radiographic images |
D0277 | $47 | $55 | Vertical bitewings - 7 to 8 radiographic images |
D0310 | $45 | $48 | Sialography |
D0320 | $230 | $321 | Temporomandibular joint arthrogram, including injection |
D0321 | $96 | $114 | Other temporomandibular joint radiographic image, by report |
D0322 | I.C. | I.C. | Tomographic survey |
D0330 | $69 | $94 | Panoramic radiographic image |
D0340 | $74 | $85 | 2D cephalometric radiographic image acquisition, measurement and analysis |
D0350 | $39 | $47 | 2D oral/facial photographic image obtained intra-orally or extra-orally |
D0364 | I.C. | I.C. | Cone beam CT capture and interpretation with limited field of view - less than one whole jaw |
D0365 | I.C. | I.C. | Cone beam CT capture and interpretation with field of view of one full dental arch - mandible |
D0366 | I.C. | I.C. | Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium |
D0367 | I.C. | I.C. | Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium |
D0368 | I.C. | I.C. | Cone beam CT capture and interpretation for TMJ series including two or more exposures |
D0369 | I.C. | I.C. | Maxillofacial MRI capture and interpretation |
D0370 | I.C. | I.C. | Maxillofacial ultrasound capture and interpretation |
D0371 | I.C. | I.C. | Sialoendoscopy capture and interpretation |
D0372 | I.C. | I.C. | Intraoral tomosynthesis - comprehensive series of radiographic images |
D0373 | I.C. | I.C. | Intraoral tomosynthesis - bitewing radiographic image |
D0374 | I.C. | I.C. | Intraoral tomosynthesis - periapical radiographic image |
D0380 | I.C. | I.C. | Cone beam CT image capture with limited field of view -less than one whole jaw |
D0381 | I.C. | I.C. | Cone beam CT image capture with field of view of one full dental arch - mandible |
D0382 | I.C. | I.C. | Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium |
D0383 | I.C. | I.C. | Cone beam CT image capture with field of view of both jaws, with or without cranium |
D0384 | I.C. | I.C. | Cone beam CT image capture for TMJ series including two or more exposures |
D0385 | I.C. | I.C. | Maxillofacial MRI image capture |
D0386 | I.C. | I.C. | Maxillofacial ultrasound image capture |
D0387 | I.C. | I.C. | Intraoral tomosynthesis - comprehensive series of radiographic image - image capture only |
D0388 | I.C. | I.C. | Intraoral tomosynthesis - bitewing radiographic image -image capture only |
D0389 | I.C. | I.C. | Intraoral tomosynthesis - periapical radiographic image -image capture only |
D0391 | I.C. | I.C. | Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report |
D0393 | I.C. | I.C. | Virtual treatment simulation using 3D image volume or surface scan |
D0394 | I.C. | I.C. | Digital subtraction of two or more images or image volumes of the same modality |
D0395 | I.C. | I.C. | Fusion of two or more 3D image volumes of one or more modalities |
D0411 | I.C. | I.C. | HbA1c in-office of service testing |
D0412 | I.C. | I.C. | Blood glucose level test- in-office using a glucose meter |
D0414 | I.C. | I.C. | Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report |
D0415 | I.C. | I.C. | Collection of microorganisms for culture and sensitivity |
D0416 | I.C. | I.C. | Viral culture |
D0417 | I.C. | I.C. | Collection and preparation of saliva sample for laboratory diagnostic testing |
D0418 | I.C. | I.C. | Analysis of saliva sample |
D0419 | I.C. | I.C. | Assessment of salivary flow by measurement |
D0422 | I.C. | I.C. | Collection and preparation of genetic sample material for laboratory analysis and report |
D0423 | I.C. | I.C. | Genetic test for susceptibility to diseases - specimen analysis |
D0425 | I.C. | I.C. | Caries susceptibility tests |
D0431 | I.C. | I.C. | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures |
D0460 | $31 | $37 | Pulp vitality tests |
D0470 | $62 | $72 | Diagnostic casts |
D0472 | $72 | $87 | Accession of tissue, gross examination, preparation, and transmission of written report |
D0473 | I.C. | I.C. | Accession of tissue, gross and microscopic examination, preparation and transmission of written report |
D0474 | I.C. | I.C. | Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report |
D0475 | I.C. | I.C. | Decalcification procedure |
D0476 | I.C. | I.C. | Special stains for microorganisms |
D0477 | I.C. | I.C. | Special stains, not for microorganisms |
D0478 | I.C. | I.C. | Immunohistochemical stains |
D0479 | I.C. | I.C. | Tissue in-situ hybridization, including interpretation |
D0480 | $54 | $65 | Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report |
D0481 | I.C. | I.C. | Electron microscopy |
D0482 | I.C. | I.C. | Direct immunofluorescence |
D0483 | I.C. | I.C. | Indirect immunofluorescence |
D0484 | I.C. | I.C. | Consultation on slides prepared elsewhere |
D0485 | I.C. | I.C. | Consultation, including preparation of slides from biopsy material supplied by referring source |
D0486 | I.C. | I.C. | Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report |
D0502 | I.C. | I.C. | Other oral pathology procedures, by report |
D0600 | I.C. | I.C. | Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum |
D0601 | I.C. | I.C. | caries risk assessment and documentation, with a finding of low risk |
D0602 | I.C. | I.C. | caries risk assessment and documentation, with a finding of moderate risk |
D0603 | I.C. | I.C. | caries risk assessment and documentation, with a finding of high risk |
D0604 | I.C. | I.C. | Antigen testing for a public health related pathogen, including coronavirus |
D0605 | I.C. | I.C. | Antibody testing for a public health related pathogen, including coronavirus |
D0701 | I.C. | I.C. | Panoramic radiographic image- image capture only |
D0702 | I.C. | I.C. | 2-D Cephalometric radiographic image- image capture only |
D0703 | I.C. | I.C. | 2-D oral/facial photographic image obtained intra-orally or extra-orally image capture only |
D0705 | I.C. | I.C. | Extra-oral posterior dental radiographic image- image capture only |
D0706 | I.C. | I.C. | Intraoral- occlusal radiographic image- image capture only |
D0707 | I.C. | I.C. | Intraoral- periapical radiographic image- image capture |
D0708 | I.C. | I.C. | Intraoral- bitewing radiographic image- image capture only |
D0709 | I.C. | I.C. | Intraoral- comprehensive series of radiographic images-image capture only |
D0801 | I.C. | I.C. | 3D dental surface scan - direct |
D0802 | I.C. | I.C. | 3D dental surface scan - indirect |
D0803 | I.C. | I.C. | 3D facial surface scan - direct |
D0804 | I.C. | I.C. | 3D facial surface scan - indirect |
D0999 | I.C. | I.C. | Unspecified diagnostic procedure, by report |
II. Preventive | |||
D1110 | $60 | $75 | Prophylaxis - adult |
D1120 | $39 | $55 | Prophylaxis - child |
D1206 | $26 | $28 | Topical application of fluoride varnish |
D1208 | $29 | $31 | Topical application of fluoride - excluding varnish |
D1310 | I.C. | I.C. | Nutritional counseling for the control of dental disease |
D1320 | I.C. | I.C. | Tobacco counseling for the control and prevention of oral disease |
D1321 | I.C. | I.C. | Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use |
D1330 | $15 | $21 | Oral hygiene instructions |
D1351 | $30 | $44 | Sealant - per tooth |
D1352 | I.C. | I.C. | Preventive resin restoration in a moderate to high caries risk patient- permanent tooth |
D1353 | I.C. | I.C. | Sealant repair - per tooth |
D1354 | $15 | $15 | Application of caries arresting medicament - per tooth |
D1355 | I.C. | I.C. | Caries preventive medicament application- per tooth |
D1510 | $191 | $229 | Space maintainer - fixed, unilateral - per quadrant |
D1516 | $306 | $345 | Space maintainer- fixed- bilateral, maxillary |
D1517 | $306 | $345 | Space maintainer- fixed- bilateral, mandibular |
D1520 | $230 | $244 | Space maintainer - removable-unilateral- per quadrant |
D1526 | $345 | $368 | Space maintainer- removable- bilateral, maxillary |
D1527 | $345 | $368 | Space maintainer- removable- bilateral, mandibular |
D1551 | I.C. | I.C. | Re-cement or re-bond bilateral space maintainer- maxillary |
D1552 | I.C. | I.C. | Re-cement or re-bond bilateral space maintainer- mandibular |
D1553 | I.C. | I.C. | Re-cement or re-bond unilateral space maintainer- per quadrant |
D1556 | I.C. | I.C. | Removal of fixed unilateral space maintainer- per quadrant |
D1557 | I.C. | I.C. | Removal of fixed bilateral space maintainer- maxillary |
D1558 | I.C. | I.C. | Removal of fixed bilateral space maintainer- mandibular |
D1575 | I.C. | I.C. | Distal shoe space maintainer - fixed, unilateral- per quadrant |
D1781 | I.C. | I.C. | Vaccine administration - human papillomavirus - Dose 1 |
D1782 | I.C. | I.C. | Vaccine administration - human papillomavirus - Dose 2 |
D1783 | I.C. | I.C. | Vaccine administration - human papillomavirus - Dose 3 |
D1999 | I.C. | I.C. | Unspecified preventive procedure, by report |
III. Restorative | |||
D2140 | $62 | $77 | Amalgam-one surface, primary or permanent |
D2150 | $77 | $95 | Amalgam-two surfaces, primary or permanent |
D2160 | $92 | $110 | Amalgam-three surfaces, primary or permanent |
D2161 | $116 | $137 | Amalgam-four or more surfaces, primary or permanent |
D2330 | $72 | $98 | Resin-based composite - one surface, anterior |
D2331 | $92 | $118 | Resin-based composite - two surfaces, anterior |
D2332 | $116 | $147 | Resin-based composite - three surfaces, anterior |
D2335 | $146 | $188 | Resin -based composite - four or more surfaces or involving incisal angle (anterior) |
D2390 | $106 | $133 | Resin-based composite crown, anterior |
D2391 | $62 | $99 | Resin-based composite - one surface, posterior |
D2392 | $77 | $123 | Resin-based composite - two surfaces, posterior |
D2393 | $92 | $133 | Resin-based composite - three surfaces, posterior |
D2394 | $116 | $182 | Resin-based composite - four or more surfaces, posterior |
D2410 | I.C. | I.C. | Gold foil - one surface |
D2420 | I.C. | I.C. | Gold foil - two surfaces |
D2430 | I.C. | I.C. | Gold foil - three surfaces |
D2510 | I.C. | I.C. | Inlay - metallic - one surface |
D2520 | I.C. | I.C. | Inlay - metallic - two surfaces |
D2530 | $307 | $367 | Inlay - metallic - three or more surfaces |
D2542 | $499 | $596 | Onlay - metallic - two surfaces |
D2543 | $690 | $788 | Onlay - metallic - three surfaces |
D2544 | $715 | $800 | Onlay - metallic - four or more surfaces |
D2610 | I.C. | I.C. | Inlay - porcelain/ceramic - one surface |
D2620 | $422 | $504 | Inlay - porcelain/ceramic - two surfaces |
D2630 | $640 | $744 | Inlay - porcelain/ceramic - three or more surfaces |
D2642 | $675 | $722 | Onlay - porcelain/ceramic - two surfaces |
D2643 | $651 | $768 | Onlay - porcelain/ceramic - three surfaces |
D2644 | $660 | $788 | Onlay - porcelain/ceramic - four or more surfaces |
D2650 | I.C. | I.C. | Inlay - resin-based composite - one surface |
D2651 | I.C. | I.C. | Inlay - resin-based composite - two surfaces |
D2652 | I.C. | I.C. | Inlay - resin-based composite - three or more surfaces |
D2662 | $613 | $656 | Onlay - resin-based composite - two surfaces |
D2663 | $612 | $727 | Onlay - resin-based composite - three surfaces |
D2664 | $612 | $731 | Onlay - resin-based composite - four or more surfaces |
D2710 | $230 | $244 | Crown - resin-based composite (indirect) |
D2712 | I.C. | I.C. | Crown - 3/4 resin-based composite (indirect) |
D2720 | $633 | $757 | Crown - resin with high noble metal |
D2721 | $460 | $550 | Crown - resin with predominantly base metal |
D2722 | $521 | $558 | Crown - resin with noble metal |
D2740 | $729 | $853 | Crown - porcelain/ceramic |
D2750 | $686 | $800 | Crown - porcelain fused to high noble metal |
D2751 | $613 | $727 | Crown - porcelain fused to predominantly base metal |
D2752 | $633 | $735 | Crown - porcelain fused to noble metal |
D2753 | I.C. | I.C. | Crown- porcelain fused to titanium and titanium alloys |
D2780 | $705 | $841 | Crown - % cast high noble metal |
D2781 | I.C. | I.C. | Crown - % cast predominately base metal |
D2782 | I.C. | I.C. | Crown - % cast noble metal |
D2783 | $682 | $812 | Crown - % porcelain/ceramic |
D2790 | $690 | $808 | Crown - full cast high noble metal |
D2791 | $538 | $641 | Crown - full cast predominantly base metal |
D2792 | $651 | $748 | Crown - full cast noble metal |
D2794 | I.C. | I.C. | Crown - titanium and titanium alloys |
D2799 | $191 | $228 | Interim crown - further treatment or completion of diagnosis necessary prior to final impression |
D2910 | $57 | $69 | Re-cement or re-bond inlay, onlay or partial coverage restoration |
D2915 | I.C. | I.C. | Re-cement or re-bond indirectly fabricated or prefabricated post and core |
D2920 | $57 | $68 | Re-cement or re-bond crown |
D2921 | I.C. | I.C. | Reattachment of tooth fragment, incisal edge or cusp |
D2928 | I.C. | I.C. | Prefabricated porcelain/ceramic crown- permanent tooth |
D2929 | I.C. | I.C. | Prefabricated porcelain/ceramic crown - primary tooth |
D2930 | $153 | $205 | Prefabricated stainless steel crown - primary tooth |
D2931 | $171 | $199 | Prefabricated stainless steel crown - permanent tooth |
D2932 | $211 | $224 | Prefabricated resin crown |
D2933 | $153 | $184 | Prefabricated stainless steel crown with resin window |
D2934 | $153 | $184 | Prefabricated esthetic coated stainless steel crown - primary tooth |
D2940 | $61 | $72 | Protective restoration |
D2941 | I.C. | I.C. | Interim therapeutic restoration- primary dentition |
D2949 | I.C. | I.C. | Restorative foundation for an indirect restoration |
D2950 | $164 | $197 | Core buildup, including any pins when required |
D2951 | $27 | $31 | Pin retention - per tooth, in addition to restoration |
D2952 | $233 | $276 | Post and core in addition to crown, indirectly fabricated |
D2953 | I.C. | I.C. | Each additional indirectly fabricated post - same tooth |
D2954 | $191 | $229 | Prefabricated post and core in addition to crown |
D2955 | I.C. | I.C. | Post removal |
D2957 | I.C. | I.C. | Each additional prefabricated post - same tooth |
D2960 | $307 | $420 | Labial veneer (resin laminate) - direct |
D2961 | $422 | $504 | Labial veneer (resin laminate) - indirect |
D2962 | $574 | $688 | Labial veneer (porcelain laminate) - laboratory |
D2971 | I.C. | I.C. | Additional procedures to customize a crown to fit under an existing partial denture framework |
D2975 | I.C. | I.C. | Coping |
D2980 | $115 | $137 | Crown repair necessitated by restorative material failure |
D2981 | I.C. | I.C. | Inlay repair necessitated by restorative material failure |
D2982 | I.C. | I.C. | Onlay repair necessitated by restorative material failure |
D2983 | I.C. | I.C. | Veneer repair necessitated by restorative material failure |
D2999 | I.C. | I.C. | Unspecified restorative procedure, by report |
IV. Endodontics | |||
D3110 | $34 | $40 | Pulp cap - direct (excluding final restoration) |
D3120 | $34 | $40 | Pulp cap - indirect (excluding final restoration) |
D3220 | $88 | $106 | Therapeutic pulpotomy (excluding final restoration) -removal of pulp coronal to the dentinocemental junction and application of medicament |
D3221 | $115 | $123 | Pulpal debridement, primary and permanent teeth |
D3222 | I.C. | I.C. | Partial pulpotomy for apexogenesis- permanent tooth with incomplete root development |
D3230 | I.C. | I.C. | Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) |
D3240 | I.C. | I.C. | Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) |
D3310 | $544 | $544 | Endodontic therapy, anterior (excluding final restoration) |
D3320 | $639 | $639 | Endodontic therapy, premolar tooth (excluding final restoration) |
D3330 | $829 | $829 | Endodontic therapy, molar tooth (excluding final restoration) |
D3331 | I.C. | I.C. | Treatment of root canal obstruction; nonsurgical access |
D3332 | $191 | $205 | Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth |
D3333 | $230 | $274 | Internal root repair of perforation defects |
D3346 | $456 | $545 | Retreatment of previous root canal therapy - anterior |
D3347 | $538 | $641 | Retreatment of previous root canal therapy - premolar |
D3348 | $613 | $789 | Retreatment of previous root canal therapy - molar |
D3351 | $122 | $146 | Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) |
D3352 | I.C. | I.C. | Apexification/recalcification - interim medication replacement |
D3353 | I.C. | I.C. | Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) |
D3355 | I.C. | I.C. | Pulpal regeneration - intial visit |
D3356 | I.C. | I.C. | Pulpal regeneration - interim medication replacement |
D3357 | I.C. | I.C. | Pulpal regeneration - completion of treatment |
D3410 | $407 | $471 | Apicoectomy - anterior |
D3421 | $460 | $550 | Apicoectomy - premolar (first root) |
D3425 | $598 | $639 | Apicoectomy - molar (first root) |
D3426 | $230 | $264 | Apicoectomy (each additional root) |
D3428 | I.C. | I.C. | Bone graft in conjunction with periradicular surgery - per tooth, single site |
D3429 | I.C. | I.C. | Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site |
D3430 | $77 | $91 | Retrograde filling - per root |
D3431 | I.C. | I.C. | Biological materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery |
D3432 | I.C. | I.C. | Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery |
D3450 | $288 | $343 | Root amputation - per root |
D3460 | $462 | $744 | Endodontic endosseous implant |
D3470 | I.C. | I.C. | Intentional re-implantation (including necessary splinting) |
D3471 | I.C. | I.C. | Surgical repair of root resorption- anterior |
D3472 | I.C. | I.C. | Surgical repair of root resorption- premolar |
D3473 | I.C. | I.C. | Surgical repair of root resorption- molar |
D3501 | I.C. | I.C. | Surgical repair of root surface without apicoectomy or repair or repair of root resorption- anterior |
D3502 | I.C. | I.C. | Surgical repair of root surface without apicectomy or repair of root resorption- premolar |
D3503 | I.C. | I.C. | Surgical repair of root surface without apicectomy or repair of root resorption- molar |
D3910 | I.C. | I.C. | Surgical procedure for isolation of tooth with rubber dam |
D3911 | I.C. | I.C. | Intraorifice barrier |
D3920 | $211 | $243 | Hemisection (including any root removal), not including root canal therapy |
D3921 | I.C. | I.C. | Decoronation or submergence of an erupted tooth |
D3950 | $69 | $111 | Canal preparation and fitting of preformed dowel or post |
D3999 | I.C. | I.C. | Unspecified endodontic procedure, by report |
V. Periodontics | |||
D4210 | $307 | $343 | Gingivectomy or gingivoplasty - Four or more contiguous teeth or bounded teeth spaces per quadrant |
D4211 | $111 | $133 | Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant |
D4212 | I.C. | I.C. | Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth |
D4230 | I.C. | I.C. | Anatomical crown exposure - Four or more contiguous teeth or bounded tooth spaces per quadrant |
D4231 | I.C. | I.C. | Anatomical crown exposure - one to three teeth or bounded tooth spaces per quadrant |
D4240 | $449 | $606 | Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant |
D4241 | I.C. | I.C. | Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant |
D4245 | I.C. | I.C. | Apically positioned flap |
D4249 | $460 | $550 | Clinical crown lengthening - hard tissue |
D4260 | $795 | $1,101 | Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant |
D4261 | $708 | $759 | Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant |
D4263 | $253 | $351 | Bone replacement graft - retained natural tooth - first site in quadrant |
D4264 | $188 | $202 | Bone replacement graft - retained natural tooth - each additional site in quadrant |
D4265 | I.C. | I.C. | Biologic materials to aid in soft and osseous tissue regeneration, per site |
D4266 | $307 | $359 | Guided tissue regeneration, natural teeth - resorbable barrier, per site |
D4267 | $307 | $328 | Guided tissue regeneration, natural teeth - non-resorbable barrier, per site |
D4268 | I.C. | I.C. | Surgical revision procedure, per tooth |
D4270 | $604 | $800 | Pedicle soft tissue graft procedure |
D4273 | $651 | $779 | Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft |
D4274 | $326 | $384 | Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) |
D4275 | I.C. | I.C. | Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft |
D4276 | I.C. | I.C. | Combined connective tissue and pedicle graft, per tooth |
D4277 | I.C. | I.C. | Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant, or edentulous tooth position in graft |
D4278 | I.C. | I.C. | Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site |
D4283 | I.C. | I.C. | Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth, implant or edentulous tooth position in same graft site |
D4285 | I.C. | I.C. | Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) |
D4286 | I.C. | I.C. | Removal of non-resorbable barrier |
D4322 | I.C. | I.C. | Splint - intra-coronal; natural teeth or prosthetic crowns |
D4323 | I.C. | I.C. | Splint - extra-coronal; natural teeth or prosthetic crowns |
D4341 | $134 | $160 | Periodontal scaling and root planing - four or more teeth per quadrant |
D4342 | $90 | $107 | Periodontal scaling and root planing - one to three teeth, per quadrant |
D4346 | $60 | $75 | Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation |
D4355 | $77 | $93 | Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit |
D4381 | $88 | $121 | Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth |
D4910 | $80 | $111 | Periodontal maintenance |
D4920 | $67 | $76 | Unscheduled dressing change (by someone other than treating dentist) |
D4921 | I.C. | I.C. | Gingival irrigation with a medicinal agent - per quadrant |
D4999 | I.C. | I.C. | Unspecified periodontal procedure, by report |
VI. Prosthodontics (Removable) | |||
D5110 | $730 | $858 | Complete denture - maxillary |
D5120 | $730 | $852 | Complete denture - mandibular |
D5130 | $767 | $935 | Immediate denture - maxillary |
D5140 | $766 | $934 | Immediate denture - mandibular |
D5211 | $556 | $650 | Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) |
D5212 | $595 | $691 | Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) |
D5213 | $1,097 | $974 | Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
D5214 | $1,134 | $986 | Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
D5221 | I.C. | I.C. | Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) |
D5222 | I.C. | I.C. | Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) |
D5223 | I.C. | I.C. | Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
D5224 | I.C. | I.C. | Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) |
D5225 | I.C. | $974 | Maxillary partial denture - flexible base (including any clasps, rests and teeth) |
D5226 | I.C. | $986 | Mandibular partial denture - flexible base (including any clasps, rests and teeth) |
D5227 | I.C. | I.C. | Immediate maxillary partial denture - flexible base (including any clasps, rests and teeth) |
D5228 | I.C. | I.C. | Immediate mandibular partial denture - flexible base (including any clasps, rests and teeth) |
D5282 | I.C. | I.C. | Removable unilateral partial denture- one piece cast metal (including retentive/clasping materials, rests and teeth), maxillary |
D5283 | I.C. | I.C. | Removable unilateral partial denture- one piece cast metal (including retentive/clasping materials, rests and teeth), mandibular |
D5284 | I.C. | I.C. | Removable unilateral partial denture- one piece flexible base (including retentive/clasping materials, rests and teeth) -per quadrant |
D5286 | I.C. | I.C. | Removable unilateral partial denture- one piece resin (including clasps and teeth) - per quadrant |
D5410 | $42 | $49 | Adjust complete denture - maxillary |
D5411 | $42 | $49 | Adjust complete denture - mandibular |
D5421 | $53 | $56 | Adjust partial denture - maxillary |
D5422 | $39 | $45 | Adjust partial denture - mandibular |
D5511 | $85 | $109 | Repair broken complete denture base, mandibular |
D5512 | $85 | $109 | Repair broken complete denture base, maxillary |
D5520 | $77 | $89 | Replace missing or broken teeth - complete denture (each tooth) |
D5611 | $77 | $93 | Repair broken resin partial denture base, mandibular |
D5612 | $77 | $93 | Repair broken resin partial denture base, maxillary |
D5621 | $104 | $121 | Repair broken cast partial denture base, mandibular |
D5622 | $104 | $121 | Repair broken cast partial denture base, maxillary |
D5630 | $99 | $107 | Repair or replace broken retentive/clasping materials - per tooth |
D5640 | $77 | $91 | Replace broken teeth - per tooth |
D5650 | $92 | $110 | Add tooth to existing partial denture |
D5660 | $98 | $125 | Add clasp to existing partial denture per tooth |
D5670 | I.C. | I.C. | Replace all teeth and acrylic on cast metal framework (maxillary) |
D5671 | I.C. | I.C. | Replace all teeth and acrylic on cast metal framework (mandibular) |
D5710 | $253 | $301 | Rebase complete maxillary denture |
D5711 | $201 | $257 | Rebase complete mandibular denture |
D5720 | $230 | $274 | Rebase maxillary partial denture |
D5721 | $284 | $323 | Rebase mandibular partial denture |
D5725 | I.C. | I.C. | Rebase hybrid prosthesis |
D5765 | I.C. | I.C. | Soft liner for complete or partial removable denture - indirect |
D5730 | $158 | $188 | Reline complete maxillary denture (direct) |
D5731 | $173 | $184 | Reline lower complete mandibular denture (direct) |
D5740 | $142 | $169 | Reline maxillary partial denture (direct) |
D5741 | $134 | $160 | Reline mandibular partial denture (direct) |
D5750 | $214 | $255 | Reline complete maxillary denture (indirect) |
D5751 | $215 | $256 | Reline complete mandibular denture (indirect) |
D5760 | $211 | $252 | Reline maxillary partial denture (indirect) |
D5761 | $211 | $252 | Reline mandibular partial denture (indirect) |
D5810 | $145 | $193 | Interim complete denture (maxillary) |
D5811 | $145 | $193 | Interim complete denture (mandibular) |
D5820 | $268 | $321 | Interim partial denture (including retentive/clasping materials, rests and teeth), maxillary |
D5821 | $295 | $316 | Interim partial denture (including retentive/clasping materials, rests and teeth), mandibular |
D5850 | $72 | $86 | Tissue conditioning, maxillary |
D5851 | $65 | $77 | Tissue conditioning, mandibular |
D5862 | $230 | $254 | Precision attachment, by report |
D5863 | I.C. | I.C. | Overdenture- complete maxillary |
D5864 | I.C. | I.C. | Overdenture- partial maxillary |
D5865 | I.C. | I.C. | Overdenture- complete mandibular |
D5866 | I.C. | I.C. | Overdenture- partial mandibular |
D5867 | I.C. | I.C. | Replacement of replaceable part of semi-precision or precision attachment, per attachment |
D5875 | I.C. | I.C. | Modification of removable prosthesis following implant surgery |
D5876 | I.C. | I.C. | Add metal substructure to acrylic full denture (per arch) |
D5899 | I.C. | I.C. | Unspecified removable prosthodontic procedure, by report |
D5911 | I.C. | I.C. | Facial moulage (sectional) |
D5912 | I.C. | I.C. | Facial moulage (complete) |
D5913 | I.C. | I.C. | Nasal prosthesis |
D5914 | I.C. | I.C. | Auricular prosthesis |
D5915 | I.C. | I.C. | Orbital prosthesis |
D5916 | I.C. | I.C. | Ocular prosthesis |
D5919 | I.C. | I.C. | Facial prosthesis |
D5922 | I.C. | I.C. | Nasal septal prosthesis |
D5923 | I.C. | I.C. | Ocular prosthesis, interim |
D5924 | I.C. | I.C. | Cranial prosthesis |
D5925 | I.C. | I.C. | Facial augmentation implant prosthesis |
D5926 | I.C. | I.C. | Nasal prosthesis, replacement |
D5927 | I.C. | I.C. | Auricular prosthesis, replacement |
D5928 | I.C. | I.C. | Orbital prosthesis, replacement |
D5929 | I.C. | I.C. | Facial prosthesis, replacement |
D5931 | I.C. | I.C. | Obturator prosthesis, surgical |
D5932 | I.C. | I.C. | Obturator prosthesis, definitive |
D5933 | I.C. | I.C. | Obturator prosthesis, modification |
D5934 | I.C. | I.C. | Mandibular resection prosthesis with guide flange |
D5935 | I.C. | I.C. | Mandibular resection prosthesis without guide flange |
D5936 | I.C. | I.C. | Obturator prosthesis, interim |
D5937 | I.C. | I.C. | Trismus appliance (not for TM treatment) |
D5951 | I.C. | I.C. | Feeding aid |
D5952 | I.C. | I.C. | Speech aid prosthesis, pediatric |
D5953 | I.C. | I.C. | Speech aid prosthesis, adult |
D5954 | I.C. | I.C. | Palatal augmentation prosthesis |
D5955 | I.C. | I.C. | Palatal lift prosthesis, definitive |
D5958 | I.C. | I.C. | Palatal lift prosthesis, interim |
D5959 | I.C. | I.C. | Palatal lift prosthesis, modification |
D5960 | I.C. | I.C. | Speech aid prosthesis, modification |
D5982 | I.C. | I.C. | Surgical stent |
D5983 | I.C. | I.C. | Radiation carrier |
D5984 | I.C. | I.C. | Radiation shield |
D5985 | I.C. | I.C. | Radiation cone locator |
D5986 | I.C. | I.C. | Fluoride gel carrier |
D5987 | I.C. | I.C. | Commissure splint |
D5988 | I.C. | I.C. | Surgical splint |
D5991 | I.C. | I.C. | Vesiculobullous disease medicament carrier |
D5992 | I.C. | I.C. | Adjust maxillofacial prosthetic appliance, by report |
D5993 | I.C. | I.C. | Maintenance and cleaning of a maxillofacial prosthesis (extra or intra-oral) other than required adjustments, by report |
D5995 | I.C. | I.C. | Periodontal medicament carrier with peripheral seal -laboratory processed- maxillary |
D5996 | I.C. | I.C. | Periodontal medicament carrier with peripheral seal -laboratory processed- mandibular |
D5999 | I.C. | I.C. | Unspecified maxillofacial prosthesis, by report |
VII. Implant Services | |||
D6010 | $1,151 | $1,374 | Surgical placement of implant body: endosteal implant |
D6011 | I.C. | I.C. | Surgical access to an implant body (second stage implant surgery) |
D6012 | I.C. | I.C. | Surgical placement of interim implant body for transitional prosthesis: endosteal implant |
D6013 | I.C. | I.C. | Surgical placement of mini implant |
D6040 | $1,534 | $1,632 | Surgical placement: eposteal implant |
D6050 | $134 | $162 | Surgical placement: transosteal implant |
D6051 | I.C. | I.C. | Interim implant abutment placement |
D6055 | $230 | $274 | Connecting bar - implant supported or abutment supported |
D6056 | $278 | $331 | Prefabricated abutment - includes modification and placement |
D6057 | $402 | $480 | Custom fabricated abutment - includes placement |
D6058 | $920 | $982 | Abutment supported porcelain/ceramic crown |
D6059 | $756 | $894 | Abutment supported porcelain fused to metal crown (high noble metal) |
D6060 | $729 | $778 | Abutment supported porcelain fused to metal crown (predominantly base metal) |
D6061 | $758 | $812 | Abutment supported porcelain fused to metal crown (noble metal) |
D6062 | $767 | $894 | Abutment supported cast metal crown (high noble metal) |
D6063 | I.C. | I.C. | Abutment supported cast metal crown (predominantly base metal) |
D6064 | $920 | $1,091 | Abutment supported cast metal crown (noble metal) |
D6065 | $920 | $1,015 | Implant supported porcelain/ceramic crown |
D6066 | $878 | $1,049 | Implant supported crown- porcelain fused to high noble alloys |
D6067 | $996 | $1,067 | Implant supported crown - high noble alloys |
D6068 | I.C. | I.C. | Abutment supported retainer for porcelain/ceramic FPD |
D6069 | I.C. | I.C. | Abutment supported retainer for porcelain fused to metal FPD (high noble metal) |
D6070 | I.C. | I.C. | Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) |
D6071 | I.C. | I.C. | Abutment supported retainer for porcelain fused to metal FPD (noble metal) |
D6072 | I.C. | I.C. | Abutment supported retainer for cast metal FPD (high noble metal) |
D6073 | I.C. | I.C. | Abutment supported retainer for cast metal FPD (predominantly base metal) |
D6074 | I.C. | I.C. | Abutment supported retainer for cast metal FPD (noble metal) |
D6075 | I.C. | I.C. | Implant supported retainer for ceramic FPD |
D6076 | I.C. | I.C. | Implant supported retainer for FPD - porcelain fused to high noble alloys |
D6077 | I.C. | I.C. | Implant supported retainer for metal FPD - high noble alloys |
D6080 | $96 | $115 | Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments |
D6081 | I.C. | I.C. | Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of implant surfaces, without flap entry and closure. |
D6082 | I.C. | I.C. | Implant supported crown- porcelain fused to predominantly base alloys |
D6083 | I.C. | I.C. | Implant supported crown- porcelain fused to noble alloys |
D6084 | I.C. | I.C. | Implant supported crown- porcelain fused to titanium or titanium alloys |
D6085 | I.C. | I.C. | Interim implant crown |
D6086 | I.C. | I.C. | Implant supported crown- predominantly base alloys |
D6087 | I.C. | I.C. | Implant supported crown- noble alloys |
D6088 | I.C. | I.C. | Implant supported crown- titanium and titanium alloys |
D6090 | I.C. | I.C. | Repair implant supported prosthesis, by report |
D6091 | I.C. | I.C. | Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment |
D6092 | I.C. | I.C. | Re-cement or re-bond implant/abutment supported crown |
D6093 | I.C. | I.C. | Re-cement or re-bond implant/abutment supported fixed partial denture |
D6094 | I.C. | I.C. | Abutment supported crown - titanium and titanium alloys |
D6095 | I.C. | I.C. | Repair implant abutment, by report |
D6096 | I.C. | I.C. | Remove broken implant retaining screw |
D6097 | I.C. | I.C. | Abutment supported crown - porcelain fused to titanium or titanium alloys |
D6098 | I.C. | I.C. | Implant supported retainer- porcelain fused to predominantly base alloys |
D6099 | I.C. | I.C. | Implant supported retainer for FPD- porcelain fused to noble alloys |
D6100 | I.C. | I.C. | Surgical removal of implant body |
D6101 | I.C. | I.C. | Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of exposed implant surfaces, including flap entry and closure |
D6102 | I.C. | I.C. | 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 | I.C. | I.C. | Bone graft for repair of peri-implant defect - does not include flap entry and closure |
D6104 | I.C. | I.C. | Bone graft at time of implant placement |
D6105 | I.C. | I.C. | Removal of implant body not requiring bone removal or flap elevation |
D6106 | I.C. | I.C. | Guided tissue regeneration - resorbable barrier, per implant |
D6107 | I.C. | I.C. | Guided tissue regeneration - non-resorbable barrier, per implant |
D6110 | I.C. | I.C. | Implant/abutment supported removable denture for edentulous arch - maxillary |
D6111 | I.C. | I.C. | Implant/abutment supported removable denture for edentulous arch - mandibular |
D6112 | I.C. | I.C. | Implant/abutment supported removable denture for partially edentulous arch - maxillary |
D6113 | I.C. | I.C. | Implant/abutment supported removable denture for partially edentulous arch - mandibular |
D6114 | I.C. | I.C. | Implant/abutment supported fixed denture for edentulous arch - maxillary |
D6115 | I.C. | I.C. | Implant/abutment supported fixed denture for edentulous arch - mandibular |
D6116 | I.C. | I.C. | Implant/abutment supported fixed denture for partially edentulous arch - maxillary |
D6117 | I.C. | I.C. | Implant/abutment supported fixed denture for partially edentulous arch- mandibular |
D6118 | I.C. | I.C. | Implant/abutment supported interim fixed denture for edentulous arch - mandibular |
D6119 | I.C. | I.C. | Implant/abutment supported interim fixed denture for edentulous arch - maxillary |
D6120 | I.C. | I.C. | Implant supported retainer- porcelain fused to titanium and titanium alloys |
D6121 | I.C. | I.C. | Implant supported retainer for metal FPD- predominantly base alloys |
D6122 | I.C. | I.C. | Implant supported retainer for metal FPD- noble alloys |
D6123 | I.C. | I.C. | Implant supported retainer for metal FPD- titanium and titanium alloys |
D6190 | I.C. | I.C. | Radiographic/surgical implant index, by report |
D6191 | I.C. | I.C. | Semi-precision abutment- placement |
D6192 | I.C. | I.C. | Semi-precision attachment - placement |
D6194 | I.C. | I.C. | Abutment supported retainer crown for FPD - titanium and titanium alloys |
D6195 | I.C. | I.C. | Abutment supported retainer- porcelain fused to titanium and titanium alloys |
D6197 | I.C. | I.C. | Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant |
D6198 | I.C. | I.C. | Remove interim implant component |
D6199 | I.C. | I.C. | Unspecified implant procedure, by report |
D6205 | I.C. | I.C. | Pontic - indirect resin based composite |
D6210 | $651 | $748 | Pontic - cast high noble metal |
D6211 | $584 | $667 | Pontic - cast predominantly base metal |
D6212 | $632 | $676 | Pontic - cast noble metal |
D6214 | I.C. | I.C. | Pontic - titanium and titanium alloys |
D6240 | $671 | $792 | Pontic - porcelain fused to high noble metal |
D6241 | $606 | $691 | Pontic - porcelain fused to predominantly base metal |
D6242 | $613 | $731 | Pontic - porcelain fused to noble metal |
D6243 | I.C. | I.C. | Pontic - porcelain fused to titanium and titanium alloys |
D6245 | I.C. | I.C. | Pontic - porcelain/ceramic |
D6250 | $703 | $807 | Pontic - resin with high noble metal |
D6251 | $517 | $575 | Pontic - resin with predominantly base metal |
D6252 | $555 | $691 | Pontic - resin with noble metal |
D6253 | I.C. | I.C. | Interim pontic - further treatment or completion of diagnosis necessary prior to final impression |
D6545 | $268 | $320 | Retainer - cast metal for resin bonded fixed prosthesis |
D6548 | I.C. | I.C. | Retainer - porcelain/ceramic for resin bonded fixed prosthesis |
D6549 | I.C. | I.C. | Resin retainer - for resin bonded fixed prosthesis |
D6600 | I.C. | I.C. | Retainer inlay - porcelain/ceramic, two surfaces |
D6601 | I.C. | I.C. | Retainer inlay - porcelain/ceramic, three or more surfaces |
D6602 | I.C. | I.C. | Retainer inlay - cast high noble metal, two surfaces |
D6603 | I.C. | I.C. | Retainer inlay - cast high noble metal, three or more surfaces |
D6604 | I.C. | I.C. | Retainer inlay - cast predominantly base metal, two surfaces |
D6605 | I.C. | I.C. | Retainer inlay - cast predominantly base metal, three or more surfaces |
D6606 | I.C. | I.C. | Retainer inlay - cast noble metal, two surfaces |
D6607 | I.C. | I.C. | Retainer inlay - cast noble metal, three or more surfaces |
D6608 | I.C. | I.C. | Retainer onlay - porcelain/ceramic, two surfaces |
D6609 | I.C. | I.C. | Retainer onlay - porcelain/ceramic, three or more surfaces |
D6610 | I.C. | I.C. | Retainer onlay - cast high noble metal, two surfaces |
D6611 | I.C. | I.C. | Retainer onlay - cast high noble metal, three or more surfaces |
D6612 | I.C. | I.C. | Retainer onlay - cast predominantly base metal, two surfaces |
D6613 | I.C. | I.C. | Retainer onlay - cast predominantly base metal, three or more surfaces |
D6614 | I.C. | I.C. | Retainer onlay - cast noble metal, two surfaces |
D6615 | I.C. | I.C. | Retainer onlay - cast noble metal, three or more surfaces |
D6624 | I.C. | I.C. | Retainer inlay - titanium |
D6634 | I.C. | I.C. | Retainer onlay - titanium |
D6710 | I.C. | I.C. | Retainer crown - indirect resin based composite |
D6720 | $527 | $671 | Retainer crown - resin with high noble metal |
D6721 | $536 | $610 | Retainer crown - resin with predominantly base metal |
D6722 | $207 | $246 | Retainer crown - resin with noble metal |
D6740 | I.C. | I.C. | Retainer crown - porcelain/ceramic |
D6750 | $678 | $779 | Retainer crown - porcelain fused to high noble metal |
D6751 | $610 | $691 | Retainer crown - porcelain fused to predominantly base metal |
D6752 | $613 | $731 | Retainer crown - porcelain fused to noble metal |
D6753 | I.C. | I.C. | Retainer crown - 3/4 porcelain fused to titanium and titanium alloys |
D6780 | $517 | $617 | Retainer crown - 3/4 cast high noble metal |
D6781 | I.C. | I.C. | Retainer crown - 3/4 cast predominately base metal |
D6782 | I.C. | I.C. | Retainer crown - 3/4 cast noble metal |
D6783 | I.C. | I.C. | Retainer crown - 3/4 porcelain/ceramic |
D6784 | I.C. | I.C. | Retainer crown - 3/4 titanium and titanium alloys |
D6790 | $703 | $897 | Retainer crown - full cast high noble metal |
D6791 | $556 | $661 | Retainer crown - full cast predominantly base metal |
D6792 | $589 | $701 | Retainer crown - full cast noble metal |
D6793 | I.C. | I.C. | Interim retainer crown - further treatment or completion of diagnosis necessary prior to final impression |
D6794 | I.C. | I.C. | Crown - titanium and titanium alloys |
D6920 | I.C. | I.C. | Connector bar |
D6930 | $72 | $87 | Recement bridge |
D6940 | $153 | $204 | Stress breaker |
D6950 | $166 | $220 | Precision attachment |
D6980 | $134 | $155 | Fixed partial denture repair necessitated by restorative material failure |
D6985 | I.C. | I.C. | Pediatric partial denture, fixed |
D6999 | I.C. | I.C. | Unspecified fixed prosthodontic procedure, by report |
X. Exodontic | |||
D7111 | $75 | $80 | Extraction, coronal remnants - primary tooth |
D7140 | $77 | $107 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
D7210 | $149 | $179 | Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated |
D7220 | $191 | $223 | Removal of impacted tooth - soft tissue |
D7230 | $249 | $286 | Removal of impacted tooth - partially bony |
D7240 | $295 | $378 | Removal of impacted tooth - completely bony |
D7241 | $326 | $427 | Removal of impacted tooth - completely bony, with unusual surgical complications |
D7250 | $144 | $173 | Surgical removal of residual tooth roots (cutting procedure) |
D7251 | I.C. | I.C. | Coronectomy - intentional partial tooth removal, impacted teeth only |
D7260 | $339 | $398 | Oroantral fistula closure |
D7261 | I.C. | I.C. | Primary closure of a sinus perforation |
D7270 | $106 | $145 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth |
D7272 | $161 | $218 | Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) |
D7280 | $380 | $452 | Exposure of an unerupted tooth |
D7282 | I.C. | I.C. | Mobilization of erupted or malpositioned tooth to aid eruption |
D7283 | $73 | $84 | Placement of device to facilitate eruption of impacted tooth |
D7285 | $122 | $146 | Incisional biopsy of oral tissue - hard (bone, tooth) |
D7286 | $164 | $197 | Incisional biopsy of oral tissue - soft |
D7287 | I.C. | I.C. | Exfoliative cytological sample collection |
D7288 | I.C. | I.C. | Brush biopsy - transepithelial sample collection |
D7290 | $79 | $109 | Surgical repositioning of teeth |
D7291 | $137 | $165 | Transseptal fiberotomy/supra crestal fiberotomy, by report |
D7292 | I.C. | I.C. | Placement of temporary anchorage device (screw retained plate) requiring flap |
D7293 | I.C. | I.C. | Placement of temporary anchorage device requiring flap |
D7294 | I.C. | I.C. | Placement of temporary anchorage device without flap |
D7295 | I.C. | I.C. | Harvest of bone for use in autogenous grafting procedure |
D7296 | I.C. | I.C. | Corticotomy - one to three teeth or tooth spaces, per quadrant |
D7297 | I.C. | I.C. | Corticotomy - four or more teeth or tooth spaces, per quadrant |
D7298 | I.C. | I.C. | Removal of temporary anchorage device (screw retained plate), requiring flap |
D7299 | I.C. | I.C. | Removal of temporary anchorage device, requiring flap |
D7300 | I.C. | I.C. | Removal of temporary anchorage device without flap |
D7310 | $142 | $163 | Alveoloplasty in conjunction with extractions-four or more teeth or tooth spaces, per quadrant |
D7311 | $128 | $146 | Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant |
D7320 | $187 | $202 | Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant |
D7321 | $149 | $162 | Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant |
D7340 | $747 | $796 | Vestibuloplasty - ridge extension (second epithelialization) |
D7350 | $943 | $1,236 | Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachments, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) |
D7410 | $115 | $124 | Excision of benign lesion up to 1.25 cm |
D7411 | $208 | $254 | Excision of benign lesion greater than 1.25 cm |
D7412 | I.C. | I.C. | Excision of benign lesion, complicated |
D7413 | I.C. | I.C. | Excision of malignant lesion up to 1.25 cm |
D7414 | I.C. | I.C. | Excision of malignant lesion greater than 1.25 cm |
D7415 | I.C. | I.C. | Excision of malignant lesion, complicated |
D7440 | $188 | $256 | Excision of malignant tumor - lesion diameter up to 1.25 cm |
D7441 | $249 | $339 | Excision of malignant tumor - lesion diameter greater than 1.25 cm |
D7450 | $248 | $252 | Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm |
D7451 | $288 | $343 | Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm |
D7460 | $121 | $142 | Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm |
D7461 | $143 | $194 | Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm |
D7465 | I.C. | I.C. | Destruction of lesion(s) by physical or chemical method, by report |
D7471 | $143 | $194 | Removal of lateral exostosis (maxilla or mandible) |
D7472 | I.C. | I.C. | Removal of torus palatinus |
D7473 | I.C. | I.C. | Removal of torus mandibularis |
D7485 | I.C. | I.C. | Surgical reduction of osseous tuberosity |
D7490 | I.C. | I.C. | Radical resection of maxilla or mandible |
D7509 | I.C. | I.C. | Marsupialization of odontogenic cyst |
D7510 | $96 | $115 | Incision and drainage of abscess - intraoral soft tissue |
D7511 | I.C. | I.C. | Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) |
D7520 | $80 | $86 | Incision and drainage of abscess - extraoral soft tissue |
D7521 | I.C. | I.C. | Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) |
D7530 | $210 | $224 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue |
D7540 | $464 | $544 | Removal of reaction-producing foreign bodies, musculoskeletal system |
D7550 | I.C. | I.C. | Partial ostectomy/sequestrectomy for removal of nonvital bone |
D7560 | $267 | $364 | Maxillary sinusotomy for removal of tooth fragment or foreign body |
D7610 | $1,250 | $1,704 | Maxilla - open reduction (teeth immobilized, if present) |
D7620 | $419 | $569 | Maxilla - closed reduction (teeth immobilized, if present) |
D7630 | $1,045 | $1,425 | Mandible - open reduction (teeth immobilized, if present) |
D7640 | $624 | $850 | Mandible - closed reduction (teeth immobilized, if present) |
D7650 | $833 | $1,135 | Malar and/or zygomatic arch - open reduction |
D7660 | $207 | $282 | Malar and/or zygomatic arch - closed reduction |
D7670 | $296 | $387 | Alveolus - closed reduction, may include stabilization of teeth |
D7671 | I.C. | I.C. | Alveolus - open reduction, may include stabilization of teeth |
D7680 | I.C. | I.C. | Facial bones - complicated reduction with fixation and multiple surgical approaches |
D7710 | $1,250 | $1,704 | Maxilla - open reduction |
D7720 | I.C. | I.C. | Maxilla - closed reduction |
D7730 | $1,045 | $1,425 | Mandible - open reduction |
D7740 | $624 | $846 | Mandible - closed reduction |
D7750 | $833 | $1,135 | Malar and/or zygomatic arch - open reduction |
D7760 | $207 | $282 | Malar and/or zygomatic arch - closed reduction |
D7770 | $312 | $380 | Alveolus - open reduction stabilization of teeth |
D7771 | I.C. | I.C. | Alveolus, closed reduction stabilization of teeth |
D7780 | $115 | $137 | Facial bones - complicated reduction with fixation and multiple surgical approaches |
D7810 | $521 | $711 | Open reduction of dislocation |
D7820 | $80 | $109 | Closed reduction of dislocation |
D7830 | I.C. | I.C. | Manipulation under anesthesia |
D7840 | $833 | $1,135 | Condylectomy |
D7850 | I.C. | I.C. | Surgical discectomy; with/without implant |
D7852 | I.C. | I.C. | Disc repair |
D7854 | I.C. | I.C. | Synovectomy |
D7856 | I.C. | I.C. | Myotomy |
D7858 | I.C. | I.C. | Joint reconstruction |
D7860 | I.C. | I.C. | Arthrotomy |
D7865 | I.C. | I.C. | Arthroplasty |
D7870 | $106 | $145 | Arthrocentesis |
D7871 | I.C. | I.C. | Nonarthroscopic lysis and lavage |
D7872 | I.C. | I.C. | Arthroscopy - diagnosis, with or without biopsy |
D7873 | I.C. | I.C. | Arthroscopy: lavage and lysis of adhesions |
D7874 | I.C. | I.C. | Arthroscopy: disc repositioning and stabilization |
D7875 | I.C. | I.C. | Arthroscopy: synovectomy |
D7876 | I.C. | I.C. | Arthroscopy: discectomy |
D7877 | I.C. | I.C. | Arthroscopy: debridement |
D7880 | $345 | $367 | Occlusal orthotic device, by report |
D7881 | I.C. | I.C. | Occlusal orthotic device adjustment |
D7899 | I.C. | I.C. | Unspecified TMD therapy, by report |
D7910 | $31 | $42 | Suture of recent small wounds up to 5 cm |
D7911 | $106 | $129 | Complicated suture - up to 5 cm |
D7912 | $106 | $145 | Complicated suture - greater than 5 cm |
D7920 | I.C. | I.C. | Skin graft (identify defect covered, location and type of graft) |
D7921 | I.C. | I.C. | Collection and application of autologous blood concentrate product |
D7922 | I.C. | I.C. | Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization, per site |
D7940 | I.C. | I.C. | Osteoplasty - for orthognathic deformities |
D7941 | I.C. | I.C. | Osteotomy - mandibular rami |
D7943 | $2,501 | $3,409 | Osteotomy - mandibular rami with bone graft; includes obtaining the graft |
D7944 | $1,015 | $1,384 | Osteotomy-segmented or subapical |
D7945 | $2,084 | $2,843 | Osteotomy - body of mandible |
D7946 | I.C. | I.C. | LeFort I (maxilla - total) |
D7947 | I.C. | I.C. | LeFort I (maxilla - segmented) |
D7948 | I.C. | I.C. | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft |
D7949 | I.C. | I.C. | LeFort II or LeFort III - with bone graft |
D7950 | $833 | $1,135 | Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla-autogenous or nonautogenous, by report |
D7951 | I.C. | I.C. | Sinus augmentation with bone or bone substitutes |
D7952 | I.C. | I.C. | Sinus augmentation via a vertical approach |
D7953 | I.C. | I.C. | Bone replacement graft for ridge preservation - per site |
D7955 | I.C. | I.C. | Repair of maxillofacial soft and/or hard tissue defect |
D7956 | I.C. | I.C. | Guided tissue regeneration, edentulous area - resorbable barrier, per site |
D7957 | I.C. | I.C. | Guided tissue regeneration, edentulous area -non-resorbable barrier, per site |
D7961 | $107 | $353 | Buccal/labial frenectomy (frenulectomy) |
D7962 | $107 | $353 | Lingual frenectomy (frenulectomy) |
D7963 | $416 | $480 | Frenuloplasty |
D7970 | $246 | $334 | Excision of hyperplastic tissue - per arch |
D7971 | $79 | $109 | Excision of pericoronal gingival |
D7972 | I.C. | I.C. | Surgical reduction of fibrous tuberosity |
D7979 | I.C. | I.C. | Non-surgical sialolithotomy |
D7980 | $106 | $145 | Surgical sialolithotomy |
D7981 | $649 | $850 | Excision of salivary gland, by report |
D7982 | $282 | $387 | Sialodochoplasty |
D7983 | $517 | $705 | Closure of salivary fistula |
D7990 | I.C. | I.C. | Emergency tracheotomy |
D7991 | I.C. | I.C. | Coronoidectomy |
D7993 | I.C. | I.C. | Surgical placement of craniofacial implant - extra oral |
D7994 | I.C. | I.C. | Surgical placement: zygomatic implant |
D7995 | I.C. | I.C. | Synthetic graft - mandible or facial bones, by report |
D7996 | I.C. | I.C. | Implant - mandible for augmentation purposes (excluding alveolar ridge), by report |
D7997 | I.C. | I.C. | Appliance removal (not by dentist who placed appliance), includes removal of archbar |
D7998 | I.C. | I.C. | Intraoral placement of a fixation device not in conjunction with a fracture |
D7999 | I.C. | I.C. | Unspecified oral surgery procedure, by report |
XI. Orthodontic | |||
D8010 | I.C. | $250 | Limited orthodontic treatment of the primary dentition |
D8020 | I.C. | $250 | Limited orthodontic treatment of the transitional dentition |
D8030 | I.C. | $250 | Limited orthodontic treatment of the adolescent dentition |
D8040 | I.C. | $250 | Limited orthodontic treatment of the adult dentition |
D8070 | I.C. | I.C. | Comprehensive orthodontic treatment of the transitional dentition |
D8080 | $1,227 | $1,302 | Comprehensive orthodontic treatment of the adolescent dentition |
D8090 | I.C. | I.C. | Comprehensive orthodontic treatment of the adult dentition |
D8210 | $85 | $95 | Removable appliance therapy |
D8220 | I.C. | I.C. | Fixed appliance therapy |
D8660 | $24 | $31 | Pre-orthodontic treatment examination to monitor growth and development |
D8670 | $215 | $288 | Periodic orthodontic treatment visit (as part of contract) |
D8680 | $85 | $102 | Orthodontic retention (removal of appliances, construction and placement of retainer(s)) |
D8681 | I.C. | I.C. | Removable orthodontic retainer adjustment |
D8690 | $122 | $136 | Orthodontic treatment (alternative billing to a contract fee) |
D8695 | I.C. | I.C. | Removal of fixed orthodontic appliances for reasons other than completion of treatment |
D8696 | I.C. | I.C. | Repair of orthodontic appliance- maxillary |
D8697 | I.C. | I.C. | Repair of orthodontic appliance- mandibular |
D8698 | I.C. | I.C. | Re-cement or re-bond fixed retainer- maxillary |
D8699 | I.C. | I.C. | Re-cement or re-bond fixed retainer- mandibular |
D8701 | I.C. | I.C. | Repair of fixed retainer, includes reattachment- maxillary |
D8702 | I.C. | I.C. | Repair of fixed retainer, includes reattachment- mandibular |
D8703 | $85 | $95 | Replacement of lost or broken retainer- maxillary |
D8704 | $85 | $95 | Replacement of lost or broken retainer- mandibular |
D8999 | I.C. | I.C. | Unspecified orthodontic procedure, by report |
XII. Adjunctive General Services | |||
D9110 | $36 | $75 | Palliative treatment of dental pain - per visit |
D9120 | I.C. | I.C. | Fixed partial denture sectioning |
D9130 | I.C. | I.C. | Temporomandibular joint dysfunction- non-invasive physical therapies |
D9210 | $11 | $15 | Local anesthesia not in conjunction with operative or surgical procedures |
D9211 | I.C. | I.C. | Regional block anesthesia |
D9212 | I.C. | I.C. | Trigeminal division block anesthesia |
D9215 | I.C. | I.C. | Local anesthesia in conjunction with operative or surgical procedures |
D9219 | I.C. | I.C. | Evaluation for moderate sedation, deep sedation or general anesthesia |
D9222 | $90 | $109 | Deep sedation/general anesthesia - first 15 minutes |
D9223 | $90 | $109 | Deep sedation/general anesthesia - each additional 15-minute increment |
D9230 | $15 | $22 | Analgesia, anxiolysis, inhalation of nitrous oxide |
D9239 | $78 | $101 | Intravenous moderate (conscious) sedation analgesia - first 15 minutes |
D9243 | $78 | $101 | Intravenous moderate (conscious) sedation analgesia - each additional 15-minute increment |
D9248 | $45 | $45 | Nonintravenous conscious sedation |
D9310 | $54 | $63 | Consultation-diagnostic service provided by dentist or physician other than requesting dentist or physician |
D9311 | I.C. | I.C. | Consultation with medical health care professional |
D9410 | $39 | $36 | House/extended care facility call, once per facility per day |
D9420 | $34 | $48 | Hospital or ambulatory surgical center call |
D9430 | $18 | $26 | Office visit for observation (during regularly scheduled hours) - no other services performed |
D9440 | $23 | $30 | Office visit - after regularly scheduled hours |
D9450 | $31 | $31 | Case presentation, subsequent to detailed and extensive treatment planing |
D9610 | $29 | $40 | Therapeutic parenteral drug, single administration |
D9612 | I.C. | I.C. | Therapeutic parenteral drugs, two or more administrations, different medications |
D9613 | I.C. | I.C. | Infiltration of sustained release therapeutic drug, per quadrant |
D9630 | $8 | $10 | Drugs or medicaments dispensed in the office for home use |
D9910 | $21 | $22 | Application of desensitizing medicament |
D9911 | I.C. | I.C. | Application of desensitizing resin for cervical and/or root surface, per tooth |
D9912 | I.C. | I.C. | Pre-visit patient screening |
D9920 | $86 | $86 | Behavior management, by report |
D9930 | $30 | $66 | Treatment of complications (postsurgical) - unusual circumstances, by report |
D9932 | I.C. | I.C. | Cleaning and inspection of removable complete denture, maxillary |
D9933 | I.C. | I.C. | Cleaning and inspection of removable complete denture, mandibular |
D9934 | I.C. | I.C. | Cleaning and inspection of removable partial denture, maxillary |
D9935 | I.C. | I.C. | Cleaning and inspection of removable partial denture, mandibular |
D9941 | $61 | $85 | Fabrication of athletic mouthguard |
D9942 | I.C. | I.C. | Repair and/or reline of occlusal guard |
D9943 | I.C. | I.C. | Occlusal guard adjustment |
D9944 | I.C. | $308 | Occlusal guard- hard appliance, full arch |
D9945 | I.C. | $308 | Occlusal guard- soft appliance, partial arch |
D9946 | I.C. | $308 | Occlusal guard- hard appliance, partial arch |
D9947 | I.C. | I.C. | Custom sleep apnea appliance fabrication and placement |
D9948 | I.C. | I.C. | Adjustment of custom sleep apnea appliance |
D9949 | I.C. | I.C. | Repair of custom sleep apnea appliance |
D9950 | $32 | $45 | Occlusion analysis - mounted case |
D9951 | $32 | $45 | Occlusal adjustment - limited |
D9952 | $149 | $179 | Occlusal adjustment - complete |
D9953 | I.C. | I.C. | Reline custom sleep apnea appliance (indirect) |
D9961 | I.C. | I.C. | Duplicate/copy patient's records |
D9970 | I.C. | I.C. | Enamel microabrasion |
D9971 | I.C. | I.C. | Odontoplasty - per tooth |
D9972 | I.C. | I.C. | External bleaching - per arch - performed in office |
D9973 | I.C. | I.C. | External bleaching - per tooth |
D9974 | I.C. | I.C. | Internal bleaching - per tooth |
D9975 | I.C. | I.C. | External bleaching for home application per arch; includes materials and fabrication of custom trays |
D9985 | I.C. | I.C. | Sales tax |
D9986 | I.C. | I.C. | Missed appointment |
D9987 | I.C. | I.C. | Cancelled appointment |
D9990 | I.C. | I.C. | Certified translation or sign-language services- per visit |
D9991 | I.C. | I.C. | Dental case management - addressing appointment compliance barriers |
D9992 | I.C. | I.C. | Dental case management - care coordination |
D9993 | I.C. | I.C. | Dental case management - motivational interviewing |
D9994 | I.C. | I.C. | Dental case management - patient education to improve oral health literacy |
D9995 | I.C. | I.C. | Teledentistry - synchronuous; real-time encounter |
D9996 | I.C. | I.C. | Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review |
D9997 | I.C. | I.C. | Dental case management- patients with special health care needs |
D9999 | I.C. | D0120 I.C. | Unspecified adjunctive procedure, by report |
101 CMR, § 314.05