La. Admin. Code tit. 40 § I-5399
CDT Code | Description | Maximum Reimbursement |
D0120 | Periodic oral evaluation-established patient | 50 |
D0140 | Limited oral evaluation-problem focused | 75 |
D0145 | Oral evaluation-patient under 3 yrs and counseling with primary caregiver | 69 |
D0150 | Comprehensive oral evaluation-new or established patient | 88 |
D0160 | Detailed and Extensive oral evaluation-problem focused | 160 |
D0170 | Re-evaluation-limited, problem focused (established patient; not post-operative visit | 70 |
D0180 | Comprehensive periodontal evaluation-new or established patient | 95 |
D0210 | Intraoral-complete series (including bitewings) | 128 |
D0220 | Intraoral-periapical first film | 28 |
D0230 | Intraoral-periapical each additional film | 24 |
D0240 | Intraoral-occlusal films | 42 |
D0250 | Intraoral-first film | 67 |
D0260 | Extraoral-first film | 55 |
D0270 | Bitewing-single film | 28 |
D0272 | Bitewing-two films | 45 |
D0273 | Bitewing-three films | 55 |
D0274 | Bitewing-four films | 65 |
D0277 | Vertical bitewings-7 to 8 films | 97 |
D0290 | Posterior-anterior or lateral skull and facial bone survey film | 135 |
D0310 | Sialography | 389 |
D0320 | Temporomandibular joint films, including injection | 592 |
D0321 | Other temporomandibular joint films | 210 |
D0322 | Tomographic survey | 530 |
D0330 | Panoramic film | 110 |
D0340 | Cephalometric film | 125 |
D0350 | Oral/facial photographic images | 71 |
D0360 | Cone beam CT-craniofacial data capture | 589 |
D0362 | Cone beam CT-two-dimensional image reconstruction using existing data, includes multiple images | 359 |
D0363 | Cone beam CT-three-dimensional image reconstruction using existing data, includes multiple images | 398 |
D0415 | Collection of microorganisms for culture and sensitivity | 186 |
D0416 | Viral culture | 168 |
D0417 | Collection and preparation of saliva sample for laboratory diagnostic testing | 167 |
D0418 | Analysis of saliva sample | 150 |
D0421 | Genetic test for susceptibility to oral diseases | 136 |
D0425 | Caries susceptibility tests | 95 |
D0431 | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures | 71 |
D0460 | Pulp vitality tests | 55 |
D0470 | Diagnostic casts | 109 |
D0472 | Accession of tissue, gross examination, preparation and transmission of written report | 118 |
D0473 | Accession of tissue, gross examination and microscopic examination, preparation and transmission of written report | 165 |
D0474 | Accession of tissue, gross examination and microscopic examination including assessment of surgical margins for presence of disease, preparation and transmission of written report | 184 |
D0480 | Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report | 176 |
D0486 | Accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report | 150 |
D0475 | Decalcification procedure | 195 |
D0476 | Special stains for microorganisms | 289 |
D0477 | Special stains not for microorganisms | 296 |
D0478 | Immunohistochemical stains | 175 |
D0479 | Tissue in-situ hybridization, including interpretation | 231 |
D0481 | Electron microscopy-diagnostic | 188 |
D0482 | Direct immunofluorescence | 105 |
D0483 | Indirect immunofluorescence | 123 |
D0484 | Consultation on slides prepared elsewhere | 168 |
D0485 | Consultation, including preparation of slides from biopsy material supplied by referring source | 180 |
D0502 | Other oral pathology procedures | 170 |
D0999 | Unspecified diagnostic procedure | BR |
D1110 | Prophylaxis-adult | 90 |
D1120 | Prophylaxis-child | 66 |
D1203 | Topical application of fluoride-child | 37 |
D1204 | Topical application of fluoride-adult | 37 |
D1206 | Topical fluoride varnish; therapeutic application for moderate to high caries risk patients | 45 |
D1310 | Nutritional counseling for control of dental disease | 70 |
D1320 | Tobacco counseling for the control and prevention of oral disease | 82 |
D1330 | Oral hygiene instructions | 55 |
D1351 | Sealant-per tooth | 54 |
D1352 | Preventative resin restoration in a moderate to high caries risk patient-permanent tooth | BR |
D1510 | Space maintainer-fixed-unilateral | 317 |
D1515 | Space maintainer-fixed-bilateral | 432 |
D1520 | Space maintainer-removable-unilateral | 390 |
D1525 | Space maintainer-removable-bilateral | 495 |
D1550 | Re-cementation of space maintainer | 83 |
D1555 | Removal of fixed space maintainer | 79 |
D2140 | Amalgam-one surface, primary or permanent | 138 |
D2150 | Amalgam-two surfaces, primary or permanent | 176 |
D2160 | Amalgam-three surfaces, primary or permanent | 214 |
D2161 | Amalgam-four surfaces, primary or permanent | 251 |
D2330 | Resin-based composite-one surface, anterior | 160 |
D2331 | Resin-based composite-two surfaces, anterior | 200 |
D2332 | Resin-based composite-three surfaces, anterior | 249 |
D2335 | Resin-based composite-four or more surfaces or involving incisal angle (anterior) | 312 |
D2390 | Resin-based composite crown-anterior | 450 |
D2391 | Resin-based composite-one surface, posterior | 177 |
D2392 | Resin-based composite-two surfaces, posterior | 230 |
D2393 | Resin-based composite-three surfaces, posterior | 284 |
D2394 | Resin-based composite-four or more surfaces posterior | 341 |
D2410 | Gold foil-one surface | 635 |
D2420 | Gold foil-two surfaces | 692 |
D2430 | Gold foil-three surfaces | 806 |
D2510 | Inlay-metallic-one surface | 833 |
D2520 | Inlay-metallic-two surfaces | 892 |
D2530 | Inlay-metallic-three or more surfaces | 965 |
D2542 | Onlay-metallic-two surfaces | 990 |
D2543 | Onlay-metallic-three surfaces | 1015 |
D2544 | Onlay-metallic-four or more surfaces | 1050 |
D2610 | Inlay-porcelain/ceramic-one surface | 907 |
D2620 | Inlay-porcelain/ceramic-two surfaces | 950 |
D2630 | Inlay-porcelain/ceramic-three or more surfaces | 995 |
D2642 | Onlay-porcelain/ceramic-two surfaces | 1008 |
D2643 | Onlay-porcelain/ceramic-three surfaces | 1049 |
D2644 | Onlay-porcelain/ceramic-four or more surfaces | 1094 |
D2650 | Inlay-resin based-one surface | 869 |
D2651 | Inlay-resin based-two surfaces | 904 |
D2652 | Inlay-resin based-three or more surfaces | 940 |
D2662 | Onlay-resin based-two surfaces | 944 |
D2663 | Onlay-resin based-three surfaces | 983 |
D2664 | Onlay-resin based-four or more surfaces | 1025 |
D2710 | Crown-resin-based composite (indirect) | 940 |
D2712 | Crown-3/4 resin-based composite (indirect) | 999 |
D2720 | Crown-resin with high noble metal | 1061 |
D2721 | Crown-resin with predominantly base metal | 998 |
D2722 | Crown-resin with noble metal | 1015 |
D2740 | Crown-porcelain/ceramic substrate | 1132 |
D2750 | Crown-porcelain fused to high noble metal | 1100 |
D2571 | Crown-porcelain fused predominantly base metal | 1029 |
D2752 | Crown-porcelain fused to noble metal | 1050 |
D2780 | Crown-3/4 cast high noble metal | 1063 |
D2781 | Crown-3/4 cast predominantly base metal | 1027 |
D2782 | Crown-3/4 cast noble metal | 1030 |
D2783 | Crown-3/4 porcelain /ceramic | 1100 |
D2790 | Crown-full cast high noble metal | 1100 |
D2791 | Crown-full cast predominantly base metal | 997 |
D2792 | Crown-full cast noble metal | 1045 |
D2794 | Crown-titanium | 1076 |
D2799 | Provisional crown | 437 |
D2910 | Recement inlay, only, or partial coverage restoration | 108 |
D2915 | Recement cast or prefabricated post and core | 114 |
D2920 | Recement crown | 109 |
D2930 | Prefabricated stainless steel crown-primary tooth | 271 |
D2931 | Prefabricated stainless steel crown-permanent tooth | 325 |
D2932 | Prefabricated resin crown | 351 |
D2933 | Prefabricated stainless steel crown with resin window | 363 |
D2934 | Prefabricated esthetic coated stainless steel crown-primary tooth | 372 |
D2940 | Protective restoration | 120 |
D2950 | Core buildup, including any pins | 271 |
D2951 | Pin retention-per tooth, in addition to restoration | 75 |
D2952 | Post and core in addition to crown, indirectly fabricated | 422 |
D2953 | Each additional indirectly fabricated post-same tooth | 312 |
D2954 | Prefabricated post and core in addition to crown | 335 |
D2955 | Post removal (not in conjunction with endodontic therapy) | 291 |
D2957 | Each additional prefabricated post-same tooth | 200 |
D2960 | Labial veneer (resin laminate)-chairside | 658 |
D2961 | Labial veneer (resin laminate)-laboratory | 975 |
D2962 | Labial veneer (porcelain laminate)-laboratory | 1150 |
D2970 | Temporary crown (fractured tooth) | 375 |
D2971 | Additional procedures to construct new crown under existing partial denture framework | 169 |
D2975 | Coping | 597 |
D2980 | Crown repair | 293 |
D2999 | Unspecified restorative procedure, | BR |
D3110 | Pulp cap-direct (excluding final restoration) | 83 |
D3120 | Pulp cap-indirect (excluding final restoration) | 84 |
D3220 | Therapeutic pulpotomy (excluding final restoration)-removal of pulp coronal to the dentinocemental junction and application of medicament | 198 |
D3221 | Pulpal debridement, primary and permanent teeth | 234 |
D3222 | Partial pulpotomy for apexogenesis-permanent tooth with incomplete root development | 298 |
D3230 | Pulpal therapy (resorbable filling)-anterior, primary tooth (excluding final restoration) | 275 |
D3240 | Pulpal therapy (resorbable filling)-posterior, primary tooth (excluding final restoration) | 312 |
D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | 725 |
D3320 | Endodontic therapy, biscuspid tooth (excluding final restoration) | 842 |
D3330 | Endodontic therapy, molar tooth (excluding final restoration) | 1009 |
D3331 | Treatment of root canal obstruction: non-surgical access | 611 |
D3332 | Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth | 444 |
D3333 | Internal root repair of perforation defects | 350 |
D3346 | Retreatment of previous root canal therapy- anterior | 850 |
D3347 | Retreatment of previous root canal therapy- bicuspid | 970 |
D3348 | Retreatment of previous root canal therapy- molar | 1132 |
D3351 | Apexification/recalcification/pulpal regeneration-initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) | 362 |
D3352 | Apexification/recalcification/pulpal regeneration-interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) | 258 |
D3353 | Apexification/recalcification/pulpal regeneration-final visit (includes completed root canal therapy-apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) | 542 |
D3354 | Pupal regeneration-(completion of regenerative treatment in an immature permanent tooth with a necrotic pulp); does not include final restoration | BR |
D3410 | Apicoectomy/periradicular surgery-anterior | 700 |
D3421 | Apicoectomy/periradicular surgery-bicuspid (first root) | 780 |
D3425 | Apicoectomy/periradicular surgery-molar (first root) | 895 |
D3426 | Apicoectomy/periradicular surgery-(each additional root) | 400 |
D3430 | Retrograde filling-per root | 280 |
D3450 | Root amputation-per root | 483 |
D3460 | Endodontic endosseous implant | 1524 |
D3470 | Intentional reimplantation (including necessary splinting) | 796 |
D3910 | Surgical procedure for isolation of tooth with rubber dam | 235 |
D3920 | Hemisection (including any root removal), not including root canal therapy | 474 |
D3950 | Canal preparation and fitting of preformed dowel or post | 258 |
D3999 | Unspecified endodontic procedure, | BR |
D4210 | Gingivectomy or gingivoplasty-four or more contiguous teeth or tooth bounded spaces per quadrant | 626 |
D4211 | Gingivectomy or gingivoplasty-one to three contiguous teeth or tooth bounded spaces per quadrant | 290 |
D4230 | Anatomical crown exposure-four or more contiguous teeth per quadrant | 698 |
D4231 | Anatomical crown exposure-one to three contiguous teeth per quadrant | 596 |
D4240 | Gingival flap procedure, including root planing- one to three contiguous teeth or tooth bounded spaces per quadrant | 738 |
D4241 | Gingival flap procedure, including root planing- four or more contiguous teeth or tooth bounded spaces per quadrant | 635 |
D4245 | Apically positioned flap | 819 |
D4249 | Clinical crown lengthening-hard tissue | 751 |
D4260 | Osseous surgery (including flap entry and closure)-four or more contiguous teeth or tooth bounded spaces per quadrant | 1074 |
D4261 | Osseous surgery (including flap entry and closure)-one to three contiguous teeth or tooth bounded spaces per quadrant | 890 |
D4263 | Bone replacement graft-each additional site in quadrant | 727 |
D4264 | Bone replacement graft-first site in quadrant | 555 |
D4265 | Biologic materials to aid in soft and osseous tissue regeneration | 550 |
D4266 | Guided tissue regeneration-resorbable barrier, per site | 831 |
D4267 | Guided tissue regeneration-nonresorbable barrier, per site (includes membrane removal) | 984 |
D4268 | Surgical revision procedure, per tooth | 810 |
D4270 | Pedical soft tissue graft procedure | 826 |
D4271 | Free soft tissue graft procedure (including donor site surgery) | 895 |
D4273 | Subepithelial connective tissue graft procedures, per tooth | 1088 |
D4274 | Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) | 670 |
D4275 | Soft tissue allograft | 969 |
D4276 | Combined connective tissue and double pedicle graft, per tooth | 1085 |
D4320 | Provisional splinting-intracoronal | 508 |
D4321 | Provisional splinting-extracoronal | 466 |
D4341 | Periodontal scaling and root planing-four or more teeth per quadrant | 251 |
D4342 | Periodontal scaling and root planing-one to three teeth per quadrant | 185 |
D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | 183 |
D4381 | Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, | 140 |
D4910 | Periodontal maintenance | 139 |
D4920 | Unscheduled dressing change (by someone other than treating dentist) | 100 |
D4999 | Unspecified periodontal procedure, | BR |
D5110 | Complete denture-maxillary | 1689 |
D5120 | Complete denture-mandibular | 1700 |
D5130 | Immediate denture-maxillary | 1831 |
D5140 | Immediate denture-mandibular | 1849 |
D5211 | Maxillary partial denture-resin base (including any conventional clasps, rests and teeth) | 1350 |
D5212 | Mandibular partial denture-resin base (including any conventional clasps, rests and teeth) | 1350 |
D5213 | Maxillary partial denture-cast base framework with resin denture bases (including any conventional clasps, rests and teeth) | 1781 |
D5214 | Mandibular partial denture-cast base framework with resin denture bases (including any conventional clasps, rests and teeth) | 1780 |
D5225 | Maxillary partial denture-flexible base (including any clasps, rests and teeth) | 1566 |
D5226 | Mandibular partial denture-flexible base (including any clasps, rests and teeth) | 1552 |
D5281 | Removable unilateral partial denture-one piece cast metal (including clasps and teeth) | 995 |
D5410 | Adjust complete denture-maxillary | 89 |
D5411 | Adjust complete denture-mandibular | 88 |
D5421 | Adjust partial denture-maxillary | 88 |
D5422 | Adjust partial denture-mandibular | 88 |
D5510 | Repair broken complete denture base | 208 |
D5520 | Replace missing or broken teeth-complete denture (each tooth) | 186 |
D5610 | Repair resin denture base | 202 |
D5620 | Repair cast framework | 291 |
D5630 | Repair or replace broken clasp | 262 |
D5640 | Replace broken teeth-per tooth | 184 |
D5650 | Add tooth to existing partial denture | 224 |
D5660 | Add clasp to existing partial denture | 268 |
D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | 735 |
D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | 750 |
D5710 | Rebase complete maxillary denture | 591 |
D5711 | Rebase complete mandibular denture | 585 |
D5720 | Rebase maxillary partial denture | 563 |
D5721 | Rebase mandibular partial denture | 562 |
D5730 | Reline complete maxillary denture (chairside) | 372 |
D5731 | Reline complete mandibular denture (chairside) | 369 |
D5740 | Reline maxillary partial denture (chairside) | 364 |
D5741 | Reline mandibular partial denture (chairside) | 368 |
D5750 | Reline complete maxillary denture (laboratory) | 475 |
D5751 | Reline complete mandibular denture (laboratory) | 475 |
D5760 | Reline maxillary partial denture (laboratory) | 469 |
D5761 | Reline mandibular partial denture (laboratory) | 472 |
D5810 | Interim complete denture (maxillary) | 848 |
D5811 | Interim complete denture (mandibular) | 853 |
D5820 | Interim partial denture (maxillary) | 690 |
D5821 | Interim partial denture (mandibular) | 690 |
D5850 | Tissue conditioning, maxillary | 204 |
D5851 | Tissue conditioning, mandibular | 205 |
D5860 | Overdenture-complete | 2121 |
D5861 | Overdenture-partial | 2048 |
D5862 | Precision attachment | 700 |
D5867 | Replacement of replaceable part of semi-precision or precision attachment (male or female component) | 385 |
D5875 | Modification of removable prosthesis following implant surgery | 393 |
D5899 | Unspecified removable prosthodontic procedure | BR |
D5911 | Facial moulage (sectional) | BR |
D5912 | Facial moulage (complete) | BR |
D5913 | Nasal prosthesis | BR |
D5914 | Auricular prosthesis | BR |
D5915 | Orbital prosthesis | BR |
D5916 | Ocular prosthesis | BR |
D5919 | Facial prosthesis | BR |
D5923 | Ocular prosthesis, interim | BR |
D5924 | Cranial prosthesis | BR |
D5925 | Facial augmentation implant prosthesis | BR |
D5926 | Nasal prosthesis, replacement | BR |
D5957 | Auricular prosthesis, replacement | BR |
D5958 | Orbital prosthesis, replacement | BR |
D5929 | Facial prosthesis, replacement | BR |
D5931 | Obturator prosthesis, surgical | BR |
D5932 | Obturator prosthesis, definitive | BR |
D5933 | Obturator prosthesis, modification | BR |
D5934 | Mandibular resection prosthesis with guide flange | BR |
D5935 | Mandibular resection prosthesis without guide flange | BR |
D5936 | Obturator prosthesis interim | BR |
D5937 | Trismus appliance (not for TMD treatment) | 746 |
D5951 | Feeding aid | 844 |
D5952 | Speech aid prosthesis, pediatric | BR |
D5953 | Speech aid prosthesis, adult | BR |
D5954 | Palatal augmentation prosthesis | BR |
D5955 | Palatal lift prosthesis, definitive | BR |
D5958 | Palatal lift prosthesis, interim | BR |
D5959 | Palatal lift prosthesis, modification | BR |
D5960 | Speech aid prosthesis modification | BR |
D5982 | Surgical stent | 450 |
D5983 | Radiation carrier | BR |
D5984 | Radiation shield | BR |
D5985 | Radiation cone locater | BR |
D5986 | Fluoride gel carrier | 210 |
D5987 | Commissure splint | BR |
D5988 | Surgical splint | 770 |
D5991 | Topical medicament carrier | 226 |
D5992 | Adjust maxillofacial prosthetic appliance | BR |
D5993 | Maintenance and cleaning of maxillofacial prosthesis (extra or intraoral) other than required adjustments | BR |
D5999 | Unspecified maxillofacial prosthesis | BR |
D6190 | Radiographic/surgical implant index | 375 |
D6010 | Surgical placement of implant body: endosteal implant | 2001 |
D6012 | Surgical placement of interim implant body for transitional prosthesis: endosteal implant | 1577 |
D6040 | Surgical placement: eposteal implant | 8380 |
D6050 | Surgical placement: transosteal implant | 5807 |
D6100 | Implant removal | 760 |
D6055 | Connecting bar-implant supported abutment support | 2900 |
D6506 | Prefabricated abutment-includes placement | 789 |
D6057 | Custom abutment-includes placement | 952 |
D6053 | Implant/abutment supported removable denture for completely edentulous arch | 2790 |
D6054 | Implant/abutment supported removable denture for partially edentulous arch | 2751 |
D6078 | Implant/abutment supported fixed denture for completely edentulous arch | 5335 |
D6079 | Implant/abutment supported fixed denture for partially edentulous arch | 3800 |
D6058 | Abutment supported porcelain/ceramic crown | 1479 |
D6059 | Abutment supported porcelain/ceramic crown (high noble metal) | 1479 |
D6060 | Abutment supported porcelain fused to metal crown (predominately base metal) | 1361 |
D6061 | Abutment supported porcelain fused to metal crown (noble metal) | 1382 |
D6062 | Abutment supported cast metal crown (high noble metal) | 1432 |
D6063 | Abutment supported cast metal crown (predominantly base metal) | 1317 |
D6064 | Abutment supported cast metal crown (noble metal) | 1366 |
D6094 | Abutment supported crown-(titanium) | 1376 |
D6065 | Implant supported porcelain/ceramic crown | 1543 |
D6066 | Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | 1545 |
D6067 | Implant supported metal crown (titanium, titanium alloy, high noble metal) | 1575 |
D6068 | Abutment supported retainer for porcelain/ceramic FPD | 1469 |
D6069 | Abutment supported retainer for porcelain fused to metal FPD (high noble metal) | 1474 |
D6070 | Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) | 1384 |
D6071 | Abutment supported retainer for porcelain fused to metal FPD (noble metal) | 1384 |
D6072 | Abutment supported retainer for cast metal FPD (high noble metal) | 1451 |
D6073 | Abutment supported retainer for porcelain cast metal FPD (predominantly base metal) | 1384 |
D6074 | Abutment supported retainer for cast metal FPD (noble metal) | 1384 |
D6194 | Abutment supported retainer crown for FPD (titanium) | 1392 |
D6075 | Implant supported retainer for ceramic FPD | 1529 |
D6076 | Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy or high noble metal | 1538 |
D6077 | Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal) | 1587 |
D6080 | Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis | 297 |
D6090 | Repair implant supported prosthesis | 742 |
D6095 | Repair implant abutment | 731 |
D6091 | Replacement of semi-precious or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment | 631 |
D6092 | Recement implant/abutment supported crown | 160 |
D6093 | Recement implant/abutment supported fixed partial denture | 182 |
D6199 | Unspecified implant procedure | BR |
D6205 | Pontic-indirect resin based composite | 988 |
D6210 | Pontic-cast high noble metal | 1089 |
D6211 | Pontic-cast predominately base metal | 998 |
D6212 | Pontic-cast noble metal | 1041 |
D6214 | Pontic-titanium | 1100 |
D6240 | Pontic-porcelain fused to high noble metal | 1100 |
D6241 | Pontic-porcelain fused to predominantly base metal | 1024 |
D6242 | Pontic-porcelain fused to noble metal | 1051 |
D6245 | Pontic-porcelain/ceramic | 1140 |
D6250 | Pontic-resin with high noble metal | 1058 |
D6251 | Pontic-resin with predominantly base metal | 1049 |
D6252 | Pontic-resin with noble metal | 1040 |
D6253 | Provisional pontic | 769 |
D6254 | Interim pontic | BR |
D6545 | Retainer-cast metal for resin bonded fixed prosthesis | 852 |
D6548 | Retainer-porcelain/ceramic for resin bonded fixed prosthesis | 950 |
D6600 | Inlay-porcelain/ceramic, two surfaces | 1000 |
D6601 | Inlay-porcelain/ceramic, three or more surfaces | 1052 |
D6602 | Inlay-cast high noble metal, two surfaces | 1015 |
D6603 | Inlay-cast high noble metal, three or more surfaces | 1050 |
D6604 | Inlay-predominantly base metal, two surfaces | 994 |
D6605 | Inlay-predominantly base metal, three or more surfaces | 1046 |
D6606 | Inlay-cast noble metal, two surfaces | 998 |
D6607 | Inlay-cast noble metal, three or more surfaces | 1050 |
D6624 | Inlay-titanium | 1080 |
D6608 | Onlay-porcelain/ceramic, two surfaces | 1061 |
D6609 | Onlay-porcelain/ceramic, three or more surfaces | 1127 |
D6610 | Onlay-cast high noble metal, two surfaces | 1074 |
D6611 | Onlay-cast high noble metal, three or more surfaces | 1111 |
D6612 | Onlay-predominantly base metal, two surfaces | 1038 |
D6613 | Onlay-predominantly base metal, three or more surfaces | 1095 |
D6614 | Onlay-cast noble metal, two surfaces | 1050 |
D6615 | Onlay-cast noble metal, three or more surfaces | 1102 |
D6634 | Onlay-titanium | 1125 |
D6710 | Crown-indirect resin based composite | 1025 |
D6720 | Crown-resin with high noble metal | 1056 |
D6721 | Crown-resin with predominantly base metal | 1032 |
D6722 | Crown-resin with noble metal | 1050 |
D6740 | Crown-porcelain/ceramic | 1146 |
D6750 | Crown-porcelain fused to high noble metal | 1107 |
D6751 | Crown-porcelain fused to predominantly base metal | 1010 |
D6752 | Crown-porcelain fused to noble metal | 1050 |
D6780 | Crown-3/4 cast high noble metal | 1075 |
D6781 | Crown-3/4 cast predominantly base metal | 1038 |
D6782 | Crown-3/4 cast noble metal | 1050 |
D6783 | Crown-3/4 porcelain/ceramic | 1100 |
D6790 | Crown-full cast high noble metal | 1085 |
D6791 | Crown-full cast predominantly base metal | 997 |
D6792 | Crown-full cast noble metal | 1040 |
D6794 | Crown-titanium | 1059 |
D6793 | Provisional retainer crown | 523 |
D6795 | Interim retainer crown | BR |
D6920 | Connector bar | 995 |
D6930 | Recement fixed partial denture | 171 |
D6940 | Stress breaker | 435 |
D6950 | Precision attachment | 650 |
D6970 | Post and core in addition to fixed partial denture retainer, indirectly fabricated | 433 |
D6972 | Prefabricated post and core in addition to fixed partial denture retainer | 344 |
D6973 | Core build up for retainer, including any pins | 275 |
D6975 | Coping-metal | 700 |
D6976 | Each additional indirectly fabricated post-same tooth | 290 |
D6977 | Each additional prefabricated post-same tooth | 204 |
D6980 | Fixed partial denture repair | 387 |
D6985 | Pediatric partial denture, fixed | 915 |
D6999 | Unspecified fixed prosthodontic procedure | BR |
D7111 | Extraction, coronal remnants-deciduous tooth | 135 |
D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | 174 |
D7210 | Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | 275 |
D7220 | Removal of impacted tooth-soft tissue | 315 |
D7230 | Removal of impacted tooth-partially bony | 395 |
D7240 | Removal of impacted tooth-completely bony | 484 |
D7241 | Removal of impacted tooth-completely bony, with unusual surgical complications | 576 |
D7250 | Surgical removal of residual tooth roots (cutting procedure) | 304 |
D7251 | Coronectomy-intentional partial tooth removal | BR |
D7260 | Oroantral fistula closure | 1026 |
D7261 | Primary closure of a sinus perforation | 757 |
D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | 561 |
D7272 | Tooth tranplantation (includes reimplantation from one site to another and splinting and/or stabilization) | 746 |
D7280 | Surgical access of an unerupted tooth | 482 |
D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | 526 |
D7283 | Placement of device to facilitate eruption of impacted tooth | 523 |
D7285 | Biopsy of oral tissue-hard (bone, tooth) | 437 |
D7286 | Biopsy of oral tissue-soft | 320 |
D7287 | Exfoliative cytological sample collection | 184 |
D7288 | Brush biopsy-transepithelial sample collection | 195 |
D7290 | Surgical repositioning of teeth | 528 |
D7291 | Transseptal fiberotomy/surpa crestal fibertotomy | 315 |
D7292 | Surgical placement: temporary anchorage device [screw retained plate] requiring surgical flap | 3300 |
D7293 | Surgical placement: temporary anchorage device requiring surgical flap | 2528 |
D7294 | Surgical placement: temporary anchorage device without surgical flap | 1619 |
D7295 | Harvest of bone for use in autogenous grafting procedure | BR |
D7310 | Alveolplasty in conjunction with extractions- four or more teeth or tooth spaces, per quadrant | 295 |
D7311 | Alveolplasty in conjunction with extractions- one to three teeth or tooth spaces, per quadrant | 309 |
D7320 | Alveolplasty not in conjunction with extractions-four or more teeth or tooth spaces, per quadrant | 443 |
D7321 | Alveolplasty not in conjunction with extractions-one to three teeth or tooth spaces, per quadrant | 437 |
D7340 | Vestibuloplasty-ridge extension (secondary epithelialization) | 1164 |
D7350 | Vestibuloplasty-ridge extension (including soft tissue graft, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) | 2467 |
D7410 | Excision of benign lesion up to 1.25 cm | 415 |
D7411 | Excision of benign lesion greater than 1.25 cm | 630 |
D7412 | Excision of benign lesion, complicated | 850 |
D7413 | Excision of malignant lesion greater than 1.25 cm | 751 |
D7414 | Excision of malignant lesion up to 1.25 cm | 1132 |
D7415 | Excision of malignant lesion, complicated | 1253 |
D7465 | Destruction of lesion(s) by physical or chemical method | 459 |
D7440 | Excision of malignant tumor-lesion diameter up to 1.25 cm | 720 |
D7441 | Excision of malignant tumor-lesion greater than 1.25 cm | 1224 |
D7450 | Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm | 588 |
D7451 | Removal of benign odontogenic cyst or tumor- lesion diameter greater than 1.25 cm | 782 |
D7460 | Removal of benign nonodontogenic cyst or tumor-lesion diameter greater than 1.25 cm | 573 |
D7461 | Removal of benign nonodontogenic cyst or tumor-lesion diameter up to 1.25 cm | 874 |
D7470 | Removal of lateral exostosis (maxilla or mandible) | 653 |
D7472 | Removal of torus palatinus | 859 |
D7473 | Removal of torus mandibularis | 761 |
D7485 | Surgical reduction of osseous tuberosity | 755 |
D7490 | Radial resection of maxilla or mandible | 8006 |
D7510 | Incision and drainage of abscess-intraoral soft tissue | 236 |
D7511 | Incision and drainage of abscess-intraoral soft tissue-complicated (includes drainage of multiple fascial spaces) | 367 |
D7520 | Incision and drainage of abscess-extraoral tissue | 169 |
D7521 | Incision and drainage of abscess-extraoral tissue-complicated (includes drainage of multiple fascial spaces) | 630 |
D7530 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | 364 |
D7540 | Removal of reaction producing foreign bodies, musculoskeletal system | 708 |
D7550 | Partial ostectomy/sequestrectomy for removal of non-vital bone | 600 |
D7560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | 1308 |
D7610 | Maxilla-open reduction (teeth immobilized, if present) | 4464 |
D7620 | Maxilla-closed reduction (teeth immobilized, if present) | 3450 |
D7630 | Mandible-open reduction (teeth immobilized, if present) | 4576 |
D7640 | Mandible-closed reduction (teeth immobilized, if present) | 3483 |
D7650 | Malar and/or zygomatic arch-open reduction | 3924 |
D7660 | Malar and/or zygomatic arch-closed reduction | 3277 |
D7670 | Alveolus closed reduction may include stabilization of teeth | 1746 |
D7671 | Alveolus open reduction may include stabilization of teeth | 1298 |
D7680 | Facial bones-complicated reduction with fixation and multiple surgical approaches | 6555 |
D7710 | Maxilla open reduction | 4568 |
D7720 | Maxilla-closed reduction | 3462 |
D7730 | Mandible-open reduction | 4826 |
D7740 | Mandible-closed reduction | 3636 |
D7750 | Malar and/or zygomatic arch-open reduction | 4230 |
D7760 | Malar and/or zygomatic arch-closed reduction | 6044 |
D7770 | Alveolus open reduction stabilization of teeth | 2794 |
D7771 | Alveolus closed reduction stabilization of teeth | 1958 |
D7780 | Facial bones-complicated reduction with fixation and multiple surgical approaches | 8587 |
D7810 | Open reduction of dislocation | 4271 |
D7820 | Closed reduction of dislocation | 644 |
D7830 | Manipulation under anesthesia | 990 |
D7840 | Condylectomy | 5466 |
D7850 | Surgical discectomy, with/without implant | 5356 |
D7852 | Disc repair | 5541 |
D7854 | Synovectomy | 5278 |
D7856 | Myotomy | 3505 |
D7858 | Joint reconstruction | BR |
D7860 | Arthrotomy | BR |
D7865 | Arthroplasty | BR |
D7870 | Arthrocentesis | 562 |
D7871 | Non-arthroscopic lysis and lavage | BR |
D7872 | Arthroscopy-diagnosis, with or without biopsy | BR |
D7873 | Arthroscopy-surgical: lavage and lysis of adhesions | BR |
D7874 | Arthroscopy-surgical: disc repositioning and stabilization | BR |
D7875 | Arthroscopy-surgical: synovectomy | BR |
D7876 | Arthroscopy-surgical: discectomy | BR |
D7877 | Arthroscopy-surgical: debridement | BR |
D7880 | Occlusal orthotic device | 990 |
D7899 | Unspecified TMD therapy | BR |
D7910 | Suture of recent small wounds up to 5 cm | 300 |
D7911 | Complicated suture-up to 5 cm | 486 |
D7912 | Complicated suture-greater than 5 cm | 792 |
D7920 | Skin graft (identify defect covered, location and type of graft | 2677 |
D7940 | Osteoplasty-for orthognathic deformaties | 4123 |
D7941 | Osteotomy-mandibular rami | 9139 |
D7943 | Osteotomy-mandibular rami with bone graft; includes obtaining the graft | 8623 |
D9744 | Osteotomy-segmented or subapical | 7006 |
D7945 | Osteotomy-body of mandible | 6983 |
D7946 | LeFort I (maxilla-total) | 8251 |
D7947 | LeFort I (maxilla-segmentedl) | 8393 |
D7948 | LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion)-without bone graft | 9586 |
D7949 | LeFort II of LeFort III-with bone graft | 11832 |
D7950 | Osseous, osteoperiosteal or cartilage graft of the mandible or maxilla-autogenous or nonautogenous | 3116 |
D7951 | Sinus augmentation with bone or bone substitutes | 3200 |
D7953 | Bone replacement graft for ridge preservation- per site | 800 |
D7955 | Repair of maxillofacial soft and/or hard tissue defect | 3807 |
D7960 | Frenulectomy-also known as frenectomy or frenotomy-separate procedure not incidental to another procedure | 450 |
D7936 | Frenuloplasty | 499 |
D7970 | Excision of hyperplastic tissue-per arch | 517 |
D7971 | Excision of pericoronal gingiva | 258 |
D7972 | Surgical reduction of fibrous tuberosity | 796 |
D7980 | Sialolithotomy | 843 |
D7981 | Excision of salivary gland | BR |
D7982 | Sialodochoplasty | 1749 |
D7983 | Closure of salivary fistula | 1528 |
D7990 | Emergency tracheotomy | 1482 |
D7991 | Coronoidectomy | 4056 |
D7995 | Synthetic graft-mandible or facial bones | BR |
D7996 | Implant-mandible for augmentation purposes (excluding alveolar ridge) | BR |
D7997 | Appliance removal (not by dentist who place appliance), includes removal of archbar | 350 |
D7998 | Intraoral placement of a fixation device not in conjunction with a fracture | 2572 |
D7999 | Unspecified oral surgery procedure | BR |
D8010 | Limited orthodontic treatment of the primary dentition | 2149 |
D8020 | Limited orthodontic treatment of the transitional dentition | 2459 |
D8030 | Limited orthodontic treatment of the adolescent dentition | 2901 |
D8040 | Limited orthodontic treatment of the adult dentition | 3237 |
D8050 | Interceptive orthodontic treatment of the primary dentition | 2590 |
D8060 | Interceptive orthodontic treatment of the transitional dentition | 2796 |
D8070 | Comprehensive orthodontic treatment of the transitional dentition | 5200 |
D8080 | Comprehensive orthodontic treatment of the adolescent dentition | 5250 |
D8090 | Comprehensive orthodontic treatment of the adult dentition | 5308 |
D8210 | Removable appliance therapy | 861 |
D8220 | Fixed appliance therapy | 968 |
D8660 | Pre-orthodontic treatment visit | 384 |
D8670 | Periodic orthodontic treatment visit (as part of contract) | 263 |
D8680 | Orthodontic retention (removal of appliances, construction and placement of retainers(s)) | 532 |
D8690 | Orthodontic treatment (alternative billing to a contract fee) | 283 |
D8691 | Repair of orthodontic appliance | 210 |
D8692 | Replacement of lost or broken retainer | 330 |
D8693 | Rebonding or recementing; and/or repair as require, of fixed retainers | 356 |
D8999 | Unspecified orthodontic procedure, | BR |
D9110 | Palliative (emergency) treatment of dental pain- minor procedure | 126 |
D9120 | Fixed partial denture sectioning | 250 |
D9210 | Local anesthesia not in conjunction with operative or surgical procedures | 74 |
D9211 | Regional block anesthesia | 96 |
D9212 | Trigeminal division block anesthesia | 272 |
D9215 | Local anesthesia in conjunction with operative or surgical procedures | 65 |
D9220 | Deep sedation/general anesthesia-first 30 minutes | 392 |
D9221 | Deep sedation/general anesthesia-each additional 15 minutes | 174 |
D9230 | Inhalation of nitrous oxide/anxiolysis analgesia | 79 |
D9241 | Intravenous conscious sedation/analgesia-first 30 minutes | 416 |
D9242 | Intravenous conscious sedation/analgesia-each additional 15 minutes | 169 |
D9248 | Non-intravenous conscious sedation | 325 |
D9310 | Consultation-diagnostic services provided by dentist or physician other than requesting dentist or physician | 129 |
D9410 | House/extended care facility call | 246 |
D9420 | Hospital or ambulatory surgery center call | 299 |
D9430 | Office visit for observation (during regularly scheduled hours)-no other services performed | 76 |
D9440 | Office visit after regularly scheduled hours | 179 |
D9450 | Case presentation, detailed and extensive treatment planning | 145 |
D9610 | Therapeutic parental drug, single administration | 111 |
D9612 | Therapeutic parental drug, two or more administrations, different medications | 193 |
D9630 | Other drugs and/or medicaments | 49 |
D9910 | Application of disensitizing medicament | 63 |
D9911 | Application of disensitizing resin for cervical and/or root surface, per tooth | 79 |
D9920 | Behavior management | 160 |
D9930 | Treatment of complications (post-surgical)- unusual circumstances | 132 |
D9940 | Occlusal guard, | 600 |
D9941 | Fabrication of athletic mouthguard | 254 |
D9942 | Repair and/or reline of occlusal guard | 250 |
D9950 | Occulusion analysis-mounted case | 344 |
D9951 | Occulusal adjustment-limited | 182 |
D9952 | Occulusal adjustment-complete | 687 |
D9970 | Enamel microabrasion | 202 |
D9971 | Odontoplasty 1-2 teeth; includes removal of enamel projections | 176 |
D9972 | External bleaching-per arch | 328 |
D9973 | External bleaching-per tooth | 231 |
D9974 | Internal bleaching-per tooth | 291 |
D9999 | Unspecified adjunctive procedure | BR |
La. Admin. Code tit. 40, § I-5399