Code |
AxiUm Description |
AGD |
ASE |
FDS |
FDS+ |
PV |
SC&G / PLUS |
BASE |
|
|
|
|
|
|
|
|
|
C1000 |
Positional Conditions |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
C2000 |
Orientation Conditions |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
C2004 |
Diasthemas |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0110.1 |
Medical History Analysis |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0110.2 |
Soft Tissue Exam |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0110.3 |
Hygiene Assessment |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0120 |
Periodic oral evaluation |
53 |
53 |
53 |
53 |
36 |
35 |
35 |
D0120.1 |
Endo Recall Performed |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0120.2 |
Annual Periodontal Evaluation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0140 |
Limited oral eval-prob focused |
74 |
74 |
79 |
85 |
56 |
64 |
64 |
D0145 |
ORAL EVAL.PATIENT UNDER 3YRS |
60 |
60 |
70 |
75 |
49 |
35 |
35 |
D0150 |
Comprehensive oral evaluation |
89 |
89 |
94 |
104 |
65 |
69 |
69 |
D0150.1 |
BOARDS ONLY Screening |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0160 |
Detailed & extensive oral eval |
134 |
155 |
162 |
178 |
83 |
101 |
84 |
D0170 |
Re-eval-limited-prob focused |
20 |
20 |
30 |
50 |
20 |
20 |
20 |
D0170.1 |
Patient Therapy Complete |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0170.2 |
EIT Periodontal Case |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0170.3 |
Scaling Complete or Competency |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0170.5 |
Pre-Prosth Audit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0170.8 |
EIT Gingivitis Case |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0170.9 |
Geriatric CCare Outcome Assmt |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0171 |
Re-evaluation - post-operative office visit |
27 |
27 |
37 |
42 |
22 |
15 |
15 |
D0180 |
Comprehensive perio evaluation |
89 |
95 |
100 |
110 |
52 |
63 |
53 |
D0180.2 |
Referral to Perio Sophomore block |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0180.3 |
Localized Periodontal Evaluation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0210 |
Intraoral-complete series |
130 |
130 |
130 |
130 |
130 |
130 |
130 |
D0220 |
Intraoral-periapical 1st image |
27 |
27 |
27 |
27 |
27 |
27 |
27 |
D0230 |
Intraoral-periapical addl film |
23 |
23 |
23 |
23 |
23 |
23 |
23 |
D0240 |
Intraoral - occlusal film |
37 |
37 |
37 |
37 |
37 |
37 |
37 |
D0250 |
Extraoral radiographic images |
51 |
51 |
51 |
51 |
51 |
51 |
51 |
D0251 |
Extra-oral posterior radiograph |
44 |
44 |
44 |
44 |
44 |
44 |
44 |
D0270 |
Bitewing - single film |
27 |
27 |
27 |
27 |
27 |
27 |
27 |
D0272 |
Bitewing - 2 films |
33 |
33 |
33 |
33 |
33 |
33 |
33 |
D0273 |
Bitewing - 3 films |
39 |
39 |
39 |
39 |
39 |
39 |
39 |
D0274 |
Bitewing - 4 films |
45 |
45 |
45 |
45 |
45 |
45 |
45 |
D0277 |
Vertical bitewing - 7-8 films |
85 |
85 |
85 |
85 |
85 |
85 |
85 |
D0290 |
Post.-ant. Skull & facial bone |
112 |
112 |
112 |
112 |
112 |
112 |
112 |
D0310 |
Sialography |
233 |
233 |
233 |
233 |
233 |
233 |
233 |
D0320 |
TMJ arthrogram, incl injection |
473 |
473 |
473 |
473 |
473 |
473 |
473 |
D0321 |
Other TMJ films, by report |
164 |
164 |
164 |
164 |
164 |
164 |
164 |
D0330 |
Panoramic film |
85 |
85 |
85 |
85 |
85 |
85 |
85 |
D0340 |
Cephalometric radiograph 2D |
108 |
108 |
108 |
108 |
108 |
108 |
108 |
D0350 |
Oral/facial images |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0364 |
Cone Beam CT - less than one jaw w interpretat |
209 |
209 |
209 |
209 |
209 |
209 |
209 |
D0365 |
Cone Beam CT - mandible with interpretation |
296 |
296 |
296 |
296 |
296 |
296 |
296 |
D0366 |
Cone Beam CT - maxilla with interpretation |
296 |
296 |
296 |
296 |
296 |
296 |
296 |
D0367 |
Cone Beam CT - maxilla & mandible w interpret |
366 |
366 |
366 |
366 |
366 |
366 |
366 |
D0368 |
Cone Beam CT for TMJ series incl 2 /more expo |
275 |
275 |
275 |
275 |
275 |
275 |
275 |
D0391 |
Interpretation of diagnostic image including rep |
108 |
108 |
108 |
108 |
108 |
108 |
108 |
D0393 |
Treatment simulation using 3D image interpret |
128 |
128 |
128 |
128 |
128 |
128 |
128 |
D0395 |
Fusion of 2+ 3D image volumes of one or more |
128 |
128 |
128 |
128 |
128 |
128 |
128 |
D0415 |
Bact. studies for path. agents |
180 |
180 |
180 |
198 |
129 |
109 |
96 |
D0416 |
Viral Culture |
151 |
151 |
151 |
151 |
123 |
80 |
80 |
D0417 |
Collection/prep of saliva sample for lab testing |
111 |
125 |
153 |
178 |
95 |
83 |
83 |
D0418 |
Analysis of saliva sample |
110 |
124 |
152 |
177 |
95 |
81 |
81 |
D0422 |
Collect/prep genetic sample for lab analysis/rep |
112 |
112 |
112 |
112 |
95 |
62 |
62 |
D0423 |
Genetic test for disease susceptibility/specime |
112 |
112 |
112 |
112 |
95 |
62 |
62 |
D0425 |
Caries susceptibility tests |
93 |
93 |
93 |
102 |
69 |
57 |
57 |
D0431 |
Adj.Pre-Diag Test/Not Biop/Cyt |
73 |
73 |
73 |
81 |
57 |
44 |
44 |
D0460 |
Pulp vitality tests |
60 |
60 |
61 |
67 |
31 |
34 |
34 |
D0470 |
Diagnostic casts |
116 |
116 |
116 |
116 |
76 |
63 |
63 |
D0471 |
Oral Pathology Laboratory |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0472 |
Accession of tissue-gross exam |
117 |
117 |
117 |
117 |
83 |
63 |
63 |
D0473 |
Accession of tissue |
151 |
151 |
151 |
151 |
118 |
80 |
80 |
D0474 |
Accession of tissue, w/ assess |
182 |
182 |
182 |
182 |
131 |
96 |
96 |
D0475 |
Decalcification Proc. |
209 |
209 |
209 |
209 |
143 |
110 |
110 |
D0476 |
Spec. Stains Microorganisms |
305 |
305 |
305 |
323 |
217 |
171 |
171 |
D0477 |
Spec. Stns. Not Microorganisms |
314 |
314 |
314 |
328 |
219 |
173 |
173 |
D0478 |
Immunohistochemical Stains |
169 |
169 |
171 |
171 |
123 |
120 |
120 |
D0479 |
Tissue In-Situ Hybridization |
233 |
233 |
240 |
263 |
166 |
130 |
130 |
D0480 |
Process & interp-cytol. smears |
178 |
178 |
178 |
182 |
123 |
96 |
96 |
D0481 |
Electron Microscop-Diag. |
175 |
175 |
206 |
227 |
131 |
96 |
96 |
D0482 |
Direct Immunofluorescence |
104 |
104 |
110 |
121 |
79 |
59 |
59 |
D0483 |
Indirect Immunoflurescence |
120 |
120 |
131 |
144 |
93 |
68 |
68 |
D0484 |
Consult on slides Elsewhere |
164 |
164 |
178 |
195 |
121 |
89 |
89 |
D0485 |
Consult.Incl. Prep of Slides |
170 |
170 |
195 |
211 |
123 |
93 |
93 |
D0486 |
Accession of Brush Biopsy, sample Micro. Exam |
164 |
164 |
164 |
175 |
112 |
87 |
87 |
D0502 |
Other oral pathology proc. |
175 |
175 |
175 |
192 |
129 |
118 |
98 |
D0601 |
Caries risk assessment and documentation - low |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0602 |
Caries risk assessment and documentation - mo |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0603 |
Caries risk assessment and documentation - hig |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D0999 |
Unspecified Diagnostic Procedure by report |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D1110 |
Prophy - adult |
97 |
97 |
97 |
107 |
72 |
66 |
66 |
D1120 |
Prophy - child |
73 |
73 |
73 |
78 |
52 |
46 |
44 |
D1208 |
Topical application of fluoride |
40 |
40 |
40 |
44 |
29 |
25 |
25 |
D1310 |
Nutritional counseling |
0 |
0 |
0 |
0 |
33 |
0 |
0 |
D1320 |
Tobacco counseling |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D1330 |
Oral hygiene instructions |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D1351 |
Sealant - per tooth |
59 |
59 |
59 |
64 |
40 |
36 |
32 |
D1352 |
Preventative Resin Restoration |
86 |
86 |
105 |
115 |
84 |
86 |
86 |
D1353 |
Sealant repair - per tooth |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D1354 |
Interim caries arresting medicament application |
41 |
41 |
41 |
49 |
29 |
25 |
25 |
D1510 |
Space maint - fixed-unilateral |
335 |
335 |
335 |
368 |
172 |
229 |
187 |
D1515 |
Space maint - fixed-bilateral |
451 |
451 |
451 |
496 |
232 |
320 |
293 |
D1520 |
Space maint - remov-unilateral |
416 |
416 |
416 |
451 |
213 |
284 |
237 |
D1525 |
Space maint - remov-bilateral |
510 |
510 |
510 |
561 |
266 |
364 |
291 |
D1550 |
Re-cementation of space maint |
89 |
89 |
89 |
95 |
45 |
59 |
48 |
D1555 |
Removal of Fixed Space Maintainer |
85 |
85 |
86 |
94 |
43 |
47 |
47 |
D2140 |
Amalgam - 1 surface |
92 |
113 |
150 |
167 |
81 |
73 |
73 |
D2150 |
Amalgam - 2 surfaces |
118 |
147 |
187 |
207 |
103 |
90 |
90 |
D2160 |
Amalgam - 3 surfaces |
147 |
178 |
228 |
240 |
119 |
113 |
113 |
D2161 |
Amalgam - 4 or more surfaces |
171 |
211 |
265 |
287 |
134 |
134 |
134 |
D2330 |
Resin-based comp-1 surf, ant. |
112 |
136 |
175 |
187 |
98 |
85 |
85 |
D2331 |
Resin-based comp-2 surf, ant. |
139 |
170 |
216 |
237 |
117 |
109 |
109 |
D2332 |
Resin-based comp-3 surf, ant. |
170 |
209 |
258 |
281 |
145 |
132 |
132 |
D2335 |
Resin-based comp-4+surf, ant. |
215 |
261 |
327 |
346 |
175 |
166 |
166 |
D2390 |
Resin-based comp crown, ant. |
313 |
381 |
469 |
505 |
232 |
232 |
232 |
D2391 |
Resin-based comp-1 surf, post. |
125 |
153 |
191 |
216 |
108 |
100 |
100 |
D2392 |
Resin-based comp-2 surf, post. |
166 |
203 |
247 |
272 |
140 |
122 |
122 |
D2393 |
Resin-based comp-3 surf, post. |
207 |
252 |
306 |
337 |
174 |
152 |
152 |
D2394 |
Resin-based comp-4+surf, post. |
244 |
294 |
365 |
387 |
187 |
188 |
188 |
D2410 |
Gold foil - 1 surface |
403 |
494 |
594 |
632 |
387 |
322 |
322 |
D2420 |
Gold foil - 2 surfaces |
448 |
548 |
680 |
693 |
442 |
378 |
378 |
D2430 |
Gold foil - 3 surfaces |
525 |
643 |
792 |
866 |
512 |
436 |
436 |
D2510 |
Inlay - metallic - 1 surface |
566 |
692 |
851 |
894 |
547 |
413 |
411 |
D2520 |
Inlay - metallic - 2 surfaces |
618 |
752 |
930 |
970 |
601 |
459 |
459 |
D2530 |
Inlay - metallic - 3 or more |
673 |
821 |
1020 |
1109 |
645 |
494 |
492 |
D2542 |
Onlay - metallic - 2 surfaces |
709 |
865 |
1044 |
1143 |
666 |
515 |
515 |
D2543 |
Onlay - metallic - 3 surfaces |
727 |
887 |
1075 |
1183 |
695 |
534 |
528 |
D2544 |
Onlay - metallic - 4 or more |
750 |
915 |
1151 |
1266 |
721 |
557 |
546 |
D2610 |
Inlay - porc/cer - 1 surface |
625 |
764 |
943 |
1006 |
602 |
462 |
455 |
D2620 |
Inlay - porc/cer - 2 surfaces |
693 |
846 |
1020 |
1077 |
642 |
501 |
501 |
D2630 |
Inlay - porc/cer - 3 or more |
730 |
890 |
1050 |
1131 |
683 |
529 |
529 |
D2642 |
Onlay - porc/cer - 2 surfaces |
746 |
910 |
1088 |
1186 |
692 |
546 |
540 |
D2643 |
Onlay - porc/cer - 3 surfaces |
774 |
944 |
1134 |
1229 |
716 |
560 |
560 |
D2644 |
Onlay - porc/cer - 4 or more |
796 |
971 |
1177 |
1245 |
744 |
584 |
576 |
D2650 |
Inlay - resin - 1 surface |
599 |
733 |
902 |
949 |
561 |
435 |
435 |
D2651 |
Inlay - resin - 2 surfaces |
636 |
774 |
930 |
997 |
590 |
460 |
460 |
D2652 |
Inlay - resin - 3 or more |
678 |
829 |
983 |
1076 |
621 |
492 |
492 |
D2662 |
Onlay - resin - 2 surfaces |
699 |
854 |
994 |
1093 |
639 |
506 |
506 |
D2663 |
Onlay - resin - 3 surfaces |
714 |
871 |
1031 |
1130 |
662 |
518 |
518 |
D2664 |
Onlay - resin - 4 or more |
746 |
909 |
1071 |
1178 |
683 |
540 |
540 |
D2710 |
Crown - resin (indirect) |
620 |
749 |
930 |
965 |
457 |
446 |
446 |
D2740 |
Crown - porcelain/ceramic subs |
809 |
982 |
1222 |
1286 |
770 |
590 |
583 |
D2750 |
Crown - PFM high noble metal |
782 |
959 |
1204 |
1346 |
571 |
571 |
571 |
D2751 |
Crown - PFM predom. base metal |
714 |
882 |
1110 |
1169 |
525 |
525 |
525 |
D2752 |
Crown - PFM noble metal |
755 |
920 |
1157 |
1275 |
548 |
548 |
548 |
D2780 |
Crown - 3/4 cast high noble mt |
782 |
959 |
1184 |
1302 |
737 |
571 |
571 |
D2783 |
Crown - 3/4 porcelain/ceramic |
809 |
982 |
1180 |
1286 |
749 |
590 |
583 |
D2790 |
Crown -Full cast high noble mt |
782 |
959 |
1219 |
1378 |
571 |
571 |
571 |
D2791 |
Crown -Full cast pred base mtl |
714 |
882 |
1089 |
1208 |
525 |
525 |
525 |
D2792 |
Crown -Full cast noble metal |
755 |
920 |
1157 |
1289 |
548 |
548 |
548 |
D2799 |
Provisional Crown |
288 |
352 |
447 |
481 |
282 |
209 |
209 |
D2910 |
Recement Inlay |
77 |
96 |
121 |
125 |
61 |
62 |
62 |
D2915 |
Recement Cast/Prefab P&C |
80 |
99 |
120 |
125 |
61 |
64 |
64 |
D2920 |
Recement crown |
77 |
96 |
119 |
125 |
61 |
62 |
62 |
D2921 |
Reattachment of tooth fragment, incisal edge o |
58 |
66 |
86 |
96 |
43 |
43 |
43 |
D2930 |
Prefab SS crown - prim. tooth |
195 |
239 |
287 |
315 |
179 |
151 |
151 |
D2931 |
Prefab SS crown - perm. tooth |
237 |
288 |
339 |
373 |
209 |
185 |
185 |
D2932 |
Prefab resin crown |
251 |
304 |
372 |
410 |
192 |
193 |
193 |
D2933 |
Prefab SS crown - resin window |
264 |
322 |
383 |
421 |
192 |
204 |
204 |
D2940 |
Sedative filling |
80 |
99 |
129 |
145 |
64 |
64 |
64 |
D2949 |
Restorative foundation for an indirect restorati |
144 |
164 |
180 |
198 |
108 |
109 |
109 |
D2950 |
Core buildup - including pins |
197 |
241 |
288 |
316 |
149 |
154 |
154 |
D2951 |
Pin retention - per tooth |
48 |
58 |
78 |
86 |
37 |
37 |
37 |
D2952 |
Cast post and core |
305 |
374 |
444 |
488 |
228 |
275 |
275 |
D2954 |
Prefab post and core |
246 |
297 |
366 |
403 |
187 |
190 |
190 |
D2955 |
Post removal |
214 |
260 |
312 |
343 |
159 |
165 |
165 |
D2957 |
Addl prefab post - same tooth |
110 |
135 |
166 |
169 |
124 |
83 |
83 |
D2960 |
Labial veneer, resin-chairside |
424 |
520 |
652 |
693 |
324 |
322 |
322 |
D2961 |
Labial veneer, resin-lab |
662 |
807 |
993 |
1025 |
480 |
480 |
480 |
D2962 |
Labial veneer, porcelain-lab |
763 |
932 |
1189 |
1256 |
568 |
554 |
554 |
D2971 |
Add'l Procedures to Construct New Crn Under E |
120 |
120 |
180 |
188 |
97 |
80 |
80 |
D2975 |
Coping - Cvring of tooth |
421 |
513 |
631 |
665 |
402 |
320 |
320 |
D2980 |
Crown repair |
203 |
247 |
305 |
337 |
155 |
156 |
156 |
D2981 |
Inlay repair of restorative material failure |
203 |
247 |
285 |
313 |
145 |
156 |
156 |
D2982 |
Onlay repair of restorative material failure |
203 |
247 |
282 |
311 |
144 |
156 |
156 |
D2983 |
Veneer repair of restorative material failure |
203 |
247 |
298 |
328 |
151 |
156 |
156 |
D2990 |
Resin infiltration of incipient smooth lesions |
125 |
141 |
168 |
185 |
108 |
100 |
100 |
D2999 |
Unspecified Restorative Procedure, by report |
50 |
50 |
50 |
50 |
86 |
47 |
47 |
D2999.1 |
Surveyed to Crown Lab Fee |
46 |
46 |
85 |
85 |
45 |
45 |
45 |
D2999A |
Porcelain Butt Margin Lab Fee (Crown) |
36 |
36 |
36 |
36 |
35 |
35 |
35 |
D3110 |
Pulp cap - direct |
58 |
71 |
89 |
98 |
45 |
45 |
45 |
D3120 |
Pulp cap - indirect |
58 |
71 |
89 |
98 |
45 |
45 |
45 |
D3220 |
Therapeutic pulpotomy |
141 |
173 |
211 |
232 |
109 |
110 |
110 |
D3221 |
Pulpal debridement, prim/perm |
155 |
188 |
238 |
265 |
120 |
120 |
120 |
D3222 |
Partial Pulp. for Apexogenesis-pmnt tth w/inco |
223 |
223 |
311 |
339 |
158 |
172 |
172 |
D3230 |
Pulpal therapy - ant, primary |
189 |
232 |
287 |
315 |
147 |
148 |
148 |
D3240 |
Pulpal therapy - post, primary |
221 |
271 |
320 |
352 |
165 |
172 |
172 |
D3310 |
Endo therapy - anterior |
519 |
631 |
810 |
891 |
373 |
373 |
373 |
D3320 |
Endo therapy - bicuspid |
613 |
748 |
912 |
1003 |
425 |
449 |
425 |
D3330 |
Endo therapy - molar |
749 |
915 |
1098 |
1208 |
509 |
509 |
509 |
D3331 |
Endo-Rt canal obstruc-non surg |
328 |
401 |
495 |
532 |
284 |
278 |
278 |
D3332 |
Endo-Incompl inop/fract tooth |
295 |
361 |
449 |
472 |
285 |
230 |
230 |
D3332.1 |
ENDO-INCOMP(PT.DID NOT RTN) |
295 |
361 |
445 |
452 |
266 |
230 |
230 |
D3333 |
Endo - internal root repair |
192 |
235 |
311 |
333 |
203 |
150 |
150 |
D3346 |
Endo retreatment - anterior |
599 |
731 |
923 |
1015 |
461 |
463 |
463 |
D3347 |
Endo retreatment - bicuspid |
688 |
838 |
1036 |
1139 |
525 |
533 |
533 |
D3348 |
Endo retreatment - molar |
816 |
995 |
1234 |
1358 |
624 |
632 |
632 |
D3351 |
Apex/recalc - initial visit |
140 |
172 |
211 |
264 |
93 |
93 |
93 |
D3352 |
Apex/recalc-interim med replac |
84 |
104 |
127 |
159 |
56 |
56 |
56 |
D3353 |
Apex/recalc - final visit |
252 |
310 |
380 |
476 |
167 |
167 |
167 |
D3355 |
Pulpal regeneration – initial visit |
140 |
172 |
211 |
264 |
93 |
93 |
93 |
D3356 |
Pulpal regeneration – interim medication replac |
84 |
104 |
127 |
159 |
56 |
56 |
56 |
D3357 |
Pulpal regeneration – completion of treatment |
252 |
288 |
288 |
316 |
166 |
167 |
167 |
D3410 |
Apicoectomy - anterior |
476 |
579 |
749 |
828 |
368 |
368 |
368 |
D3421 |
Apicoectomy - bicusp(1st root) |
538 |
656 |
813 |
880 |
416 |
418 |
418 |
D3425 |
Apicoectomy - molar (1st root) |
621 |
759 |
939 |
1033 |
479 |
482 |
482 |
D3426 |
Apicoectomy - addl roots |
254 |
312 |
390 |
415 |
232 |
197 |
197 |
D3427 |
Periradicular surgery without apicoectomy |
386 |
386 |
386 |
570 |
379 |
381 |
381 |
D3428 |
Bone graft in conjunction with periradicular sur |
173 |
173 |
208 |
277 |
173 |
173 |
173 |
D3429 |
Bone graft w/periradicular surg–each adl tooth |
173 |
173 |
208 |
277 |
173 |
173 |
173 |
D3430 |
Retrograde filling - per root |
192 |
237 |
293 |
322 |
149 |
150 |
150 |
D3431 |
Biologic mat soft and osse tiss regen w/periradi |
329 |
403 |
418 |
460 |
322 |
256 |
256 |
D3432 |
Guided tiss regen resorb barr, per site w/perira |
293 |
293 |
476 |
524 |
293 |
293 |
293 |
D3450 |
Root amputation - per root |
350 |
424 |
513 |
564 |
411 |
270 |
270 |
D3470 |
Intentional reimplantation |
592 |
725 |
848 |
933 |
426 |
459 |
459 |
D3910 |
Surg isolate of tth,rubber dam |
141 |
173 |
226 |
255 |
141 |
111 |
111 |
D3920 |
Hemisection, incl root removal |
329 |
403 |
495 |
544 |
256 |
256 |
256 |
D3950 |
Canal prep with dowel or post |
182 |
222 |
268 |
295 |
170 |
141 |
141 |
D3999 |
Unspecified endo procedure |
0 |
0 |
0 |
0 |
123 |
0 |
0 |
D4000 |
Surgical Services |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D4000.1 |
Surgical Workup-Part C |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D4000.2 |
Performance of Surgery |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D4000.3 |
Post Surgical Evaluation & Sum |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D4000.4 |
Surgical Assist |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D4000.5 |
Interactive Surgical Assist |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D4200.2 |
Bone Screw & Tack |
87 |
87 |
87 |
89 |
89 |
89 |
89 |
D4210 |
Gingivectomy/plasty -4 of more |
454 |
555 |
665 |
732 |
340 |
353 |
353 |
D4211 |
Gingivectomy/plasty - 1-3 tth |
202 |
247 |
291 |
353 |
161 |
182 |
182 |
D4212 |
Ginigivectomy or gingivoplasty for restoration p |
202 |
233 |
241 |
265 |
122 |
123 |
123 |
D4230 |
Anatom.Crn.Exp. 4 or More TTH |
433 |
528 |
650 |
664 |
363 |
337 |
337 |
D4231 |
Anatom.Crn Expo. 1-3 TTH |
413 |
502 |
622 |
661 |
317 |
319 |
319 |
D4240 |
Gingival flap - 4 of more/quad |
536 |
653 |
782 |
861 |
405 |
416 |
416 |
D4241 |
Gingival flap - 1-3 teeth/quad |
452 |
552 |
650 |
715 |
335 |
352 |
352 |
D4245 |
Apically positioned flap |
638 |
776 |
847 |
932 |
569 |
494 |
494 |
D4249 |
Clinical crown elong, hard tis |
547 |
668 |
803 |
884 |
413 |
423 |
423 |
D4260 |
Osseous surgery-4 or more/quad |
770 |
938 |
1128 |
1240 |
582 |
593 |
593 |
D4261 |
Osseous surgery - 1-3 tth/quad |
638 |
777 |
931 |
1024 |
469 |
495 |
495 |
D4263 |
Bone Repl Graft - first site |
173 |
173 |
208 |
277 |
173 |
173 |
173 |
D4263.1 |
Bone Replacement Material |
398 |
398 |
402 |
530 |
0 |
0 |
0 |
D4263.2 |
Bio oss 2.0c/4.2ccbone |
438 |
438 |
442 |
449 |
0 |
0 |
0 |
D4264 |
Bone Repl Graft - add'l site |
173 |
173 |
208 |
277 |
173 |
173 |
173 |
D4265 |
Biologic materials-tissue regn |
329 |
403 |
511 |
520 |
322 |
256 |
256 |
D4265.1 |
Osteocel 1 cc |
0 |
959 |
0 |
0 |
0 |
0 |
0 |
D4266 |
Guided tissue regen-resorb-incl barrier |
293 |
293 |
312 |
342 |
293 |
293 |
293 |
D4267 |
Guided tissue regen-nonresorb-no barrier |
293 |
293 |
312 |
342 |
293 |
293 |
293 |
D4268 |
Surg. revision proc. - per tth |
595 |
726 |
834 |
917 |
550 |
459 |
459 |
D4270 |
Pedicle soft tissue graft |
603 |
736 |
869 |
956 |
446 |
468 |
468 |
D4273 |
autogenous connective tissue graft, first site in |
780 |
953 |
1115 |
1227 |
574 |
582 |
577 |
D4274 |
Distal or proximal wedge |
500 |
610 |
697 |
766 |
461 |
371 |
371 |
D4275 |
non-autogenous connective tissue graft, first sit |
731 |
891 |
1037 |
1140 |
666 |
538 |
538 |
D4276 |
Comb. connective tissue/graft |
825 |
1009 |
1151 |
1266 |
744 |
610 |
610 |
D4277 |
free soft tissue graft (recipient & donor sites); fi |
642 |
784 |
967 |
1040 |
497 |
497 |
497 |
D4278 |
Free soft tissue graft (recipient & donor sites); a |
214 |
260 |
323 |
346 |
250 |
166 |
166 |
D4283 |
Autogenous connective tissue graft, each addtl |
391 |
477 |
582 |
623 |
289 |
291 |
289 |
D4285 |
non-autogenous connective tissue graft, each a |
391 |
477 |
582 |
623 |
289 |
291 |
289 |
D4320 |
Provisional Splint Intracoronal |
368 |
449 |
546 |
601 |
282 |
286 |
286 |
D4321 |
Provisional Splint Extracoronal |
329 |
403 |
501 |
551 |
255 |
256 |
256 |
D4341 |
Scaling/rt planing 4 or more |
186 |
223 |
275 |
303 |
86 |
137 |
77 |
D4342 |
Scaling/rt planing 1-3 teeth |
118 |
146 |
189 |
220 |
63 |
85 |
48 |
D4355 |
Full mouth debridement |
137 |
166 |
195 |
214 |
115 |
106 |
106 |
D4381 |
Antimicrobial Agent- per site |
69 |
69 |
92 |
101 |
62 |
68 |
68 |
D4910 |
Periodontal maintenance |
100 |
121 |
146 |
161 |
78 |
78 |
78 |
D4920 |
Unscheduled dressing change |
73 |
89 |
110 |
112 |
56 |
59 |
59 |
D4921 |
Gingival irrigation – per quadrant |
13 |
15 |
23 |
25 |
10 |
10 |
10 |
D4999 |
Unspecified periodontal proc. |
0 |
0 |
0 |
0 |
46 |
0 |
0 |
D5110 |
Complete denture - maxillary |
1174 |
1439 |
1775 |
1907 |
848 |
848 |
848 |
D5120 |
Complete denture - mandibular |
1174 |
1439 |
1775 |
1933 |
848 |
848 |
848 |
D5130 |
Immediate denture - maxillary |
1267 |
1556 |
1925 |
2078 |
915 |
915 |
915 |
D5140 |
Immediate denture - mandibular |
1267 |
1556 |
1925 |
2078 |
915 |
915 |
915 |
D5211 |
Max. part denture - resin base |
499 |
607 |
732 |
805 |
461 |
602 |
361 |
D5212 |
Mand Part denture - resin base |
499 |
607 |
732 |
805 |
461 |
602 |
361 |
D5213 |
Max partial - cast metal frame |
1216 |
1488 |
1879 |
1959 |
882 |
875 |
875 |
D5214 |
Mand partial -cast metal frame |
1216 |
1488 |
1879 |
1959 |
884 |
875 |
875 |
D5221 |
Immediate maxillary partial denture – resin bas |
849 |
1048 |
1297 |
1519 |
658 |
617 |
617 |
D5222 |
Immediate mandibular partial denture – resin b |
849 |
1048 |
1297 |
1519 |
665 |
617 |
617 |
D5223 |
Immediate maxillary partial denture – cast met |
1338 |
1637 |
2066 |
2155 |
971 |
962 |
962 |
D5224 |
immediate mandibular partial denture – cast m |
1338 |
1637 |
2066 |
2155 |
973 |
962 |
962 |
D5225 |
Max Partial Dent. Flex Base |
539 |
647 |
782 |
865 |
501 |
608 |
401 |
D5226 |
Mand. Partial Dent. Flex Base |
539 |
647 |
782 |
865 |
501 |
608 |
401 |
D5410 |
Adjust complete denture - max |
62 |
77 |
95 |
105 |
48 |
48 |
48 |
D5411 |
Adjust complete denture - mand |
62 |
77 |
95 |
105 |
48 |
48 |
48 |
D5421 |
Adjust partial denture - max |
62 |
77 |
95 |
105 |
48 |
48 |
48 |
D5422 |
Adjust partial denture - mand |
62 |
77 |
95 |
105 |
48 |
48 |
48 |
D5510 |
Repair denture base |
149 |
181 |
228 |
251 |
115 |
134 |
134 |
D5520 |
Replace teeth - per tooth |
121 |
160 |
202 |
223 |
103 |
104 |
104 |
D5610 |
RPD:Resin denture base |
156 |
176 |
220 |
242 |
112 |
120 |
120 |
D5620 |
RPD:Cast framework |
216 |
259 |
308 |
338 |
158 |
174 |
165 |
D5630 |
RPD:Repair or replace broken clasp per tooth |
189 |
233 |
286 |
314 |
147 |
148 |
148 |
D5640 |
RPD:Broken teeth - per tooth |
128 |
154 |
202 |
226 |
100 |
100 |
100 |
D5650 |
RPD:Add tooth - existing partial |
162 |
192 |
241 |
265 |
121 |
122 |
122 |
D5660 |
RPD:Add clasp - existing partial per tooth |
189 |
233 |
282 |
311 |
147 |
148 |
148 |
D5670 |
RPD:Replace all teeth - max |
507 |
648 |
751 |
832 |
471 |
384 |
384 |
D5671 |
RPD:Replace all teeth - mand |
507 |
648 |
751 |
832 |
471 |
384 |
384 |
D5700 |
Denture Rebase Procedures |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D5710 |
Rebase complete max. denture |
424 |
520 |
628 |
690 |
317 |
329 |
329 |
D5711 |
Rebase complete mand. denture |
424 |
520 |
628 |
690 |
318 |
329 |
329 |
D5720 |
Rebase max. partial denture |
404 |
497 |
612 |
673 |
307 |
315 |
315 |
D5721 |
Rebase mand. partial denture |
404 |
497 |
606 |
666 |
307 |
315 |
315 |
D5730 |
Reline comp max - chairside |
269 |
331 |
400 |
440 |
205 |
211 |
211 |
D5731 |
Reline comp mand - chairside |
269 |
331 |
396 |
436 |
203 |
211 |
211 |
D5740 |
Reline max part - chairside |
269 |
331 |
385 |
423 |
246 |
211 |
211 |
D5741 |
Reline mand part - chairside |
269 |
331 |
390 |
429 |
250 |
211 |
211 |
D5750 |
Reline comp max - laboratory |
351 |
423 |
498 |
548 |
257 |
270 |
270 |
D5751 |
Reline comp mand - laboratory |
351 |
423 |
507 |
558 |
259 |
270 |
270 |
D5760 |
Reline max part - laboratory |
351 |
423 |
502 |
552 |
256 |
270 |
270 |
D5761 |
Reline mand part - laboratory |
351 |
423 |
502 |
552 |
256 |
270 |
270 |
D5810 |
Interim complete denture - Max |
608 |
673 |
835 |
938 |
557 |
426 |
408 |
D5811 |
Interim complete denture -Mand |
608 |
673 |
835 |
938 |
557 |
426 |
408 |
D5820 |
Interim partial denture - Max |
499 |
607 |
732 |
805 |
461 |
361 |
361 |
D5821 |
Interim partial denture - Mand |
499 |
607 |
732 |
805 |
461 |
361 |
361 |
D5850 |
Tissue conditioning - Max. |
141 |
173 |
213 |
235 |
106 |
106 |
106 |
D5851 |
Tissue conditioning - Mand. |
141 |
173 |
212 |
234 |
106 |
106 |
106 |
D5862 |
Precision attachment |
486 |
486 |
751 |
826 |
465 |
287 |
287 |
D5862.1 |
Prec.Attach. Locator |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D5863 |
Overdenture - Complete Maxillary |
1194 |
1459 |
1815 |
1967 |
868 |
868 |
868 |
D5864 |
Overdenture - Partial Maxillary |
1236 |
1508 |
1919 |
2019 |
902 |
895 |
895 |
D5865 |
Overdenture – complete mandibular |
1194 |
1459 |
1815 |
1993 |
868 |
868 |
868 |
D5866 |
Overdenture – partial mandibular |
1236 |
1508 |
1919 |
2019 |
904 |
895 |
895 |
D5867 |
Replace, part of semi-prec att |
262 |
325 |
366 |
388 |
228 |
242 |
242 |
D5867.1 |
Replace Locator Male |
50 |
50 |
50 |
50 |
50 |
50 |
50 |
D5875 |
Mod of rem prosth after implnt |
262 |
326 |
402 |
455 |
253 |
234 |
234 |
D5899 |
Unspec removable prosth proc. |
397 |
459 |
588 |
647 |
313 |
315 |
315 |
D5913 |
Nasal Prosthesis |
2401 |
2782 |
3810 |
4001 |
1905 |
1905 |
1905 |
D5914 |
Auricular prosthesis |
2400 |
2452 |
3808 |
3999 |
1904 |
1904 |
1904 |
D5932 |
Obturator prosthesis - def. |
0 |
2076 |
2396 |
3465 |
0 |
0 |
0 |
D5933 |
Obturator prosthesis - mod. |
0 |
388 |
443 |
493 |
0 |
0 |
0 |
D5936 |
Obturator prosthesis - int. |
0 |
1051 |
1051 |
1801 |
0 |
0 |
0 |
D5953 |
Speech aid prosthesis - adult |
0 |
1428 |
2515 |
2772 |
0 |
0 |
0 |
D5955 |
Palatal lift prosthesis - def. |
0 |
1166 |
2993 |
3465 |
0 |
0 |
0 |
D5958 |
Palatal lift prosthesis - int. |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D5982 |
Surgical stent |
296 |
364 |
460 |
510 |
282 |
231 |
231 |
D5986 |
Fluoride gel carrier |
141 |
166 |
212 |
239 |
135 |
106 |
106 |
D5988 |
Surgical splint |
567 |
684 |
787 |
865 |
529 |
408 |
408 |
D5991 |
Topical Medicament Carrier |
141 |
166 |
212 |
255 |
135 |
106 |
106 |
D5992 |
Adjust Maxillofacial Prostethic Appl, by report |
65 |
70 |
92 |
107 |
50 |
45 |
45 |
D5993 |
Maint/Cleaning of Maxillofac Prosth, by report ( |
11 |
11 |
11 |
11 |
10 |
10 |
10 |
D5994 |
Periodontal medicament carrier w/peripheral s |
215 |
245 |
326 |
359 |
164 |
164 |
164 |
D5999 |
Unspecified max. prosthesis |
564 |
653 |
854 |
939 |
445 |
447 |
447 |
D6010 |
Surg placement, endosteal impl |
950 |
950 |
1650 |
2272 |
950 |
950 |
950 |
D6010.3 |
STAGE 2 IMPLANT SURGERY |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D6011 |
Second stage implant surgery |
192 |
218 |
291 |
321 |
146 |
146 |
146 |
D6012 |
Surg Plcmnt Intrm Endo Implt |
410 |
410 |
1230 |
1330 |
410 |
410 |
410 |
D6013 |
Surgical placement of mini implant |
500 |
500 |
965 |
1003 |
500 |
500 |
500 |
D6040 |
Surg placement, eposteal impl |
6017 |
7381 |
7934 |
8727 |
5538 |
4593 |
4593 |
D6050 |
Surg placemnt, transosteal imp |
4132 |
5068 |
5633 |
6196 |
3793 |
3154 |
3154 |
D6051 |
Interim abutment includes placement & remov |
288 |
352 |
434 |
466 |
282 |
209 |
209 |
D6052 |
Semi-precision attachment abutment |
473 |
476 |
745 |
783 |
521 |
279 |
279 |
D6053.2 |
Retrofit Denture to Impl |
608 |
718 |
889 |
904 |
549 |
455 |
455 |
D6055 |
Dental implant supported bar |
1821 |
2067 |
2720 |
3465 |
1924 |
1308 |
1308 |
D6056 |
Prefabricated abutment |
300 |
300 |
600 |
660 |
200 |
200 |
200 |
D6057 |
Custom abutment |
400 |
400 |
800 |
1036 |
300 |
300 |
300 |
D6057.0 |
Custom Abutment (Implant Crown) |
527 |
588 |
936 |
1031 |
379 |
350 |
350 |
D6057.1 |
Custom Abutment-Titanium |
554 |
619 |
1012 |
1134 |
499 |
371 |
371 |
D6057.2 |
Custom Abutment-Zirconium |
554 |
619 |
1012 |
1134 |
499 |
371 |
371 |
D6058 |
Abut supported - porc/ceramic crown |
958 |
1081 |
1463 |
1643 |
970 |
705 |
700 |
D6059 |
Abutment - PFM,high noble metl |
959 |
1123 |
1497 |
1668 |
978 |
696 |
696 |
D6060 |
Abutment - PFM, based metal |
886 |
1036 |
1328 |
1565 |
902 |
642 |
642 |
D6061 |
Abutment - PFM, noble metal |
921 |
1081 |
1386 |
1553 |
940 |
667 |
667 |
D6062 |
Abutment-cast metal,high noble |
959 |
1123 |
1498 |
1648 |
978 |
696 |
696 |
D6064 |
Abutment-cast metal,noble metl |
921 |
1081 |
1387 |
1553 |
940 |
667 |
667 |
D6065 |
Implant - porc/ceramic crown |
993 |
1164 |
1579 |
1737 |
1014 |
720 |
720 |
D6065.2 |
Implant Retained Temporary |
247 |
247 |
252 |
252 |
125 |
125 |
125 |
D6066 |
Implant - PFM,high noble metal |
959 |
1123 |
1598 |
1758 |
752 |
696 |
696 |
D6067 |
Implant -metal crwn,high noble |
959 |
1123 |
1555 |
1760 |
767 |
696 |
696 |
D6068 |
Abutment-retainer,porc/cer FPD |
993 |
1164 |
1522 |
1674 |
1014 |
720 |
720 |
D6069 |
Abutment-ret,PFM FPD,high nobl |
959 |
1123 |
1490 |
1682 |
978 |
696 |
696 |
D6070 |
Abutment-ret,PFM FPD,base metl |
886 |
1036 |
1424 |
1587 |
902 |
642 |
642 |
D6071 |
Abutment-ret,PFM FPD,noble met |
921 |
1081 |
1443 |
1588 |
940 |
667 |
667 |
D6072 |
Abut-ret,cast metal-high noble FPD |
959 |
1123 |
1497 |
1693 |
978 |
696 |
696 |
D6073 |
Abut-ret,cast metal-base metal FPD |
886 |
1036 |
1368 |
1587 |
902 |
642 |
642 |
D6074 |
Abut-ret,cast metal-noble metl FPD |
921 |
1081 |
1429 |
1595 |
940 |
667 |
667 |
D6075 |
Implant -retainer for cer. FPD |
958 |
1164 |
1497 |
1650 |
1040 |
705 |
700 |
D6076 |
Implant - retainer for PFM FPD |
958 |
1123 |
1568 |
1650 |
1043 |
714 |
714 |
D6077 |
Implant - ret, cast metal FPD |
958 |
1123 |
1599 |
1767 |
1069 |
714 |
714 |
D6080 |
Implant maintenance proc. |
195 |
239 |
296 |
296 |
196 |
151 |
151 |
D6090 |
Repair implant -prosthesis |
539 |
663 |
785 |
863 |
509 |
401 |
401 |
D6091 |
Replace Implt Supptd Attachmen |
135 |
135 |
220 |
296 |
112 |
112 |
112 |
D6092 |
Recement Implt Supp Crn |
108 |
133 |
164 |
181 |
111 |
83 |
83 |
D6093 |
Recement Implt Supp FPD |
108 |
133 |
176 |
207 |
120 |
83 |
83 |
D6095 |
Repair implant abutment |
539 |
663 |
753 |
828 |
499 |
401 |
401 |
D6100 |
Implant removal by report |
567 |
684 |
795 |
874 |
520 |
421 |
414 |
D6100.1 |
Implant Removal by Rpt |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D6101 |
debride of a periimpl defect of exp imp surf incl |
452 |
552 |
583 |
641 |
297 |
352 |
352 |
D6102 |
debrid oss contr periimplant defect; inc surf exp |
582 |
661 |
826 |
909 |
439 |
441 |
441 |
D6103 |
bone graft for repair of periimplant defect – w/ |
173 |
173 |
208 |
277 |
309 |
173 |
173 |
D6104 |
bone graft at time of implant placement |
173 |
173 |
202 |
277 |
173 |
173 |
173 |
D6110 |
Impl/Abut Supported Remv Denture Edentulou |
1274 |
1539 |
2144 |
2216 |
948 |
948 |
948 |
D6111 |
Impl/Abut Supported Remv Denture Edentulou |
1274 |
1539 |
2144 |
2216 |
948 |
948 |
948 |
D6112 |
Impl/Abut Supported Remv Dent Part Edentulo |
1316 |
1588 |
2036 |
2216 |
982 |
975 |
975 |
D6113 |
Impl/Abut Supported Remv Dent Part Edentulo |
1316 |
1588 |
2036 |
2216 |
984 |
975 |
975 |
D6114 |
Hybrid4 Impl/Abut Supported Fixd Denture Ede |
5829 |
6240 |
6240 |
6864 |
8405 |
8446 |
8446 |
D6115 |
Hybrid4 Impl/Abut Supported Fixd Denture Ede |
5829 |
5987 |
5987 |
6586 |
8405 |
8446 |
8446 |
D6116 |
Hybrid4 Impl/Abut Supported Fixd Dent Part Ed |
4526 |
4526 |
4526 |
4979 |
7354 |
7390 |
7390 |
D6117 |
Impl/Abut Supported Fixd Dent Part Edentulous |
4771 |
4771 |
4771 |
5248 |
7354 |
7390 |
7390 |
D6190 |
Radio/Surg Implt Index(stent)by rpt |
370 |
370 |
418 |
460 |
317 |
198 |
182 |
D6190.1 |
Nobelbiocare Stent |
431 |
601 |
610 |
622 |
427 |
427 |
427 |
D6199 |
Unspec. implant proc by report |
304 |
353 |
464 |
506 |
240 |
241 |
241 |
D6205 |
Pontic Indirect Resin Bds Com |
742 |
909 |
1020 |
1122 |
683 |
536 |
536 |
D6210 |
Pontic - cast high noble metal |
782 |
959 |
1187 |
1317 |
748 |
566 |
566 |
D6211 |
Pontic - cast predom base metl |
714 |
882 |
1077 |
1134 |
702 |
520 |
520 |
D6212 |
Pontic - cast noble metal |
755 |
920 |
1128 |
1189 |
723 |
542 |
542 |
D6240 |
Pontic-porc fuse to high noble |
782 |
959 |
1187 |
1329 |
763 |
566 |
566 |
D6241 |
Pontic-porc fuse to base metal |
714 |
882 |
1107 |
1217 |
714 |
520 |
520 |
D6242 |
Pontic-porc fuse to noble metl |
755 |
920 |
1140 |
1267 |
733 |
542 |
542 |
D6245 |
Pontic-porcelain/ceramic |
809 |
982 |
1205 |
1325 |
770 |
590 |
576 |
D6250 |
Pontic-resin, high noble metal |
782 |
959 |
1151 |
1266 |
755 |
566 |
566 |
D6251 |
Pontic-resin, predom base metl |
714 |
882 |
1089 |
1214 |
711 |
520 |
520 |
D6252 |
Pontic-resin with noble metal |
755 |
920 |
1128 |
1240 |
722 |
542 |
542 |
D6253 |
Provisional pontic |
320 |
320 |
770 |
847 |
205 |
205 |
205 |
D6545 |
Retainer, metal, resin bond FP |
539 |
663 |
817 |
938 |
531 |
393 |
393 |
D6548 |
Retainer, porc/cera, bonded FP |
708 |
829 |
994 |
1093 |
668 |
492 |
492 |
D6549 |
Resin retainer - for resin bonded fixed prosthes |
539 |
663 |
817 |
938 |
531 |
393 |
393 |
D6600 |
Inlay - porc/ceramic, 2 surf |
748 |
913 |
1024 |
1126 |
683 |
549 |
543 |
D6601 |
Inlay - porc/ceramic, 3+ surf |
806 |
982 |
1102 |
1213 |
723 |
587 |
584 |
D6602 |
Inlay - high noble mtl, 2 surf |
767 |
936 |
1056 |
1162 |
704 |
560 |
555 |
D6603 |
Inlay - high noble mtl, 3+ sur |
820 |
1003 |
1086 |
1194 |
741 |
595 |
595 |
D6604 |
Inlay - pred. base mtl, 2 surf |
732 |
893 |
1004 |
1105 |
670 |
531 |
531 |
D6605 |
Inlay - pred. base mtl, 3+ sur |
784 |
957 |
1046 |
1151 |
719 |
573 |
570 |
D6606 |
Inlay - cast noble mtl, 2 surf |
753 |
918 |
1031 |
1134 |
683 |
550 |
547 |
D6607 |
Inlay - cast noble mtl, 3+ sur |
801 |
979 |
1062 |
1168 |
722 |
589 |
582 |
D6608 |
Onlay - porc/ceramic, 2 surf |
806 |
982 |
1121 |
1233 |
722 |
587 |
584 |
D6609 |
Onlay - porc/ceramic, 3+ surf |
878 |
1071 |
1182 |
1300 |
785 |
650 |
637 |
D6611 |
Onlay - high noble mtl, 3+ sur |
896 |
1094 |
1203 |
1323 |
794 |
657 |
650 |
D6720 |
Retainer Crown - resin, high noble metl |
782 |
959 |
1098 |
1208 |
722 |
571 |
571 |
D6721 |
Retainer Retainer Crown - resin, predom base m |
714 |
882 |
1089 |
1163 |
684 |
525 |
525 |
D6722 |
Retainer Crown - resin, noble metal |
755 |
920 |
1107 |
1217 |
702 |
548 |
548 |
D6740 |
Retainer Crown - porcelain/ceramic |
809 |
982 |
1211 |
1332 |
770 |
590 |
583 |
D6750 |
Retainer Crown Porcelain fused - high noble |
782 |
959 |
1204 |
1346 |
750 |
571 |
571 |
D6751 |
Retainer Crown - porcelain to base metl |
714 |
882 |
1109 |
1225 |
686 |
525 |
525 |
D6752 |
Retainer Crown - porcelain to noble mtl |
755 |
920 |
1153 |
1268 |
719 |
548 |
548 |
D6783 |
Retainer Crown - 3/4 porcelain/ceramic |
809 |
982 |
1180 |
1301 |
756 |
590 |
583 |
D6790 |
Retainer Crown-full cast high noble mtl |
782 |
959 |
1192 |
1328 |
737 |
571 |
571 |
D6791 |
Retainer Crown-full cast pred. base mtl |
714 |
882 |
1098 |
1208 |
683 |
525 |
525 |
D6792 |
Retainer Crown - full cast noble metal |
755 |
920 |
1134 |
1265 |
711 |
548 |
548 |
D6793 |
Provisional retainer crown |
329 |
403 |
496 |
612 |
321 |
240 |
240 |
D6900 |
Other FPD Services |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D6900.1 |
Clips (Hader bar) |
96 |
96 |
114 |
160 |
100 |
100 |
100 |
D6900.2 |
Replace Prosth. Screw |
96 |
96 |
114 |
160 |
100 |
100 |
100 |
D6900.3 |
Replace Locator or ERA male |
0 |
67 |
82 |
112 |
0 |
0 |
0 |
D6920 |
Connector bar |
730 |
882 |
1086 |
1149 |
674 |
648 |
648 |
D6930 |
Recement FPD |
115 |
146 |
183 |
201 |
89 |
89 |
89 |
D6940 |
Stress breaker |
296 |
364 |
431 |
474 |
282 |
231 |
231 |
D6950 |
Precision attachment |
473 |
573 |
690 |
759 |
442 |
364 |
364 |
D6980 |
FPD repair |
269 |
331 |
408 |
451 |
260 |
211 |
211 |
D6999 |
Unspecified fixed pros. proc. |
156 |
180 |
247 |
259 |
123 |
123 |
123 |
D6999 A |
Porcelain Butt Margin Lab Fee (Bridge) |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D6999.1 |
$50 Add'tl Dental Lab Cost for Prosth Procedure |
50 |
50 |
50 |
50 |
50 |
50 |
50 |
D6999.2 |
$100 Add'tl Dental Lab Cost for Prosth Procedu |
100 |
100 |
100 |
100 |
100 |
100 |
100 |
D6999.3 |
$105 Add'tl Dental Lab Cost for Prosth Procedu |
105 |
105 |
105 |
105 |
105 |
105 |
105 |
D6999.4 |
$250 Add'tl Dental Lab Cost for Prosth Procedu |
250 |
250 |
250 |
250 |
250 |
250 |
250 |
D6999.5 |
$315 Add'tl Dental Lab Cost for Prosth Procedu |
315 |
315 |
315 |
315 |
315 |
315 |
315 |
D6999.6 |
$500 Add'tl Dental Lab Cost for Prosth Procedu |
500 |
500 |
500 |
500 |
500 |
500 |
500 |
D6999.7 |
$750 Add'tl Dental Lab Cost for Prosth Procedu |
750 |
750 |
750 |
750 |
750 |
750 |
750 |
D6999.8 |
$1000 Add'tl Dental Lab Cost for Prosth Proced |
1000 |
1000 |
1000 |
1000 |
1000 |
1000 |
1000 |
D6999.9 |
$1200 Add'tl Dental Lab Cost for Prosth Proced |
1200 |
1200 |
1200 |
1200 |
1200 |
1200 |
1200 |
D7111 |
Coronal remnants - decid. tth |
96 |
114 |
144 |
159 |
73 |
74 |
74 |
D7140 |
Extraction, eruptd tth/ exp rt |
114 |
138 |
175 |
208 |
118 |
86 |
86 |
D7210 |
Surg removal of erupted tooth |
195 |
208 |
298 |
328 |
174 |
145 |
133 |
D7220 |
Rem of impacted tth, soft tiss |
227 |
259 |
339 |
373 |
168 |
174 |
148 |
D7230 |
Rem of impacted tth, part bony |
288 |
298 |
424 |
466 |
245 |
214 |
174 |
D7240 |
Rem of impacted tth, comp bony |
375 |
375 |
513 |
564 |
321 |
263 |
231 |
D7241 |
Rem of impacted tth, surg comp |
424 |
520 |
589 |
648 |
481 |
401 |
401 |
D7250 |
Removal of residual tth roots |
217 |
265 |
324 |
357 |
165 |
169 |
169 |
D7260 |
Oroantral fistula closure |
534 |
650 |
804 |
925 |
499 |
414 |
414 |
D7261 |
Primary closure of sinus perf. |
523 |
642 |
787 |
818 |
403 |
408 |
408 |
D7270 |
Tooth reimplantation/stabilize |
386 |
472 |
584 |
648 |
300 |
301 |
301 |
D7272 |
Tooth transplantation |
494 |
605 |
740 |
804 |
385 |
386 |
386 |
D7280 |
Surg exposure - ortho reasons |
338 |
418 |
514 |
555 |
428 |
258 |
258 |
D7282 |
Mobilization of tth for erupt |
377 |
460 |
523 |
575 |
332 |
269 |
269 |
D7283 |
Plcmt device facil. eruption |
393 |
478 |
511 |
563 |
347 |
290 |
290 |
D7285 |
Biopsy of oral tissue - hard |
276 |
336 |
420 |
495 |
215 |
215 |
215 |
D7286 |
Biopsy of oral tissue - soft |
217 |
265 |
337 |
389 |
267 |
169 |
169 |
D7287 |
Cytology sample collection |
104 |
126 |
175 |
219 |
90 |
80 |
80 |
D7288 |
Brush biopsy transepithelial |
118 |
146 |
183 |
230 |
94 |
90 |
90 |
D7290 |
Surgical reposition of teeth |
341 |
414 |
519 |
571 |
267 |
269 |
269 |
D7291 |
Transseptal fiberotomy |
217 |
265 |
317 |
349 |
209 |
167 |
167 |
D7292 |
Sur.Plcmt Tmp Anch. Flap(plt& |
1797 |
2206 |
2719 |
3046 |
2151 |
1399 |
1399 |
D7293 |
Surg.plcmt tmp anchor w/flap |
500 |
500 |
1633 |
1663 |
500 |
500 |
500 |
D7294 |
Surg Plcmt Tmp Anch. w/o Flap |
500 |
500 |
1253 |
1273 |
500 |
500 |
500 |
D7295 |
Harvest of Bone (autogenous grafting) |
319 |
386 |
435 |
479 |
230 |
245 |
245 |
D7310 |
Alveoloplasty with extractions |
208 |
254 |
313 |
349 |
160 |
161 |
161 |
D7311 |
Alveoplasty w/1-3 ext.per quad |
226 |
278 |
314 |
345 |
160 |
176 |
176 |
D7320 |
Alveoloplasty w/o ext 4 tth sp |
301 |
364 |
454 |
511 |
231 |
231 |
231 |
D7321 |
Alveoplasty not w/1-3 ext quad |
319 |
386 |
435 |
479 |
230 |
245 |
245 |
D7330 |
Vestibuloplasty |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7340 |
Vestibuloplasty - second epith |
702 |
850 |
1048 |
1109 |
591 |
593 |
593 |
D7350 |
Vestibuloplasty -tissue grafts |
1374 |
1654 |
2041 |
2078 |
1193 |
1001 |
1001 |
D7410 |
Excision, benign lesion<1.25cm |
285 |
332 |
428 |
476 |
213 |
213 |
213 |
D7411 |
Excision, benign lesion>1.25cm |
425 |
520 |
628 |
690 |
326 |
328 |
328 |
D7412 |
Excision, ben lesion complicat |
564 |
684 |
845 |
859 |
454 |
456 |
456 |
D7413 |
Excision, malig lesion>1.25cm |
474 |
581 |
714 |
811 |
466 |
399 |
399 |
D7414 |
Excision, malig lesion>1.25cm |
710 |
869 |
967 |
1109 |
683 |
596 |
596 |
D7415 |
Excision, malig lesion complic |
871 |
973 |
1191 |
1280 |
810 |
666 |
666 |
D7425 |
Removal, Tumor, Cyst, Neoplasm |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7440 |
Exc malign tumor-lesion<1.25cm |
394 |
574 |
786 |
825 |
393 |
393 |
393 |
D7441 |
Exc malign tumor-lesion>1.25cm |
708 |
1015 |
1391 |
1460 |
695 |
695 |
695 |
D7450 |
Rem odonto cyst/tumor < 1.25cm |
359 |
438 |
544 |
574 |
313 |
313 |
313 |
D7451 |
Rem odonto cyst/tumor > 1.25cm |
459 |
561 |
714 |
811 |
426 |
428 |
428 |
D7460 |
Rem nonodonto cyst < 1.25cm |
365 |
446 |
549 |
588 |
307 |
309 |
309 |
D7461 |
Rem nonodonto cyst > 1.25cm |
494 |
605 |
745 |
832 |
472 |
475 |
475 |
D7465 |
Destruction of lesion |
244 |
295 |
375 |
429 |
249 |
188 |
188 |
D7470 |
Excision of Bone Tissue |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7471 |
Removal of lateral exostosis |
449 |
548 |
680 |
739 |
347 |
347 |
347 |
D7472 |
Removal of torus palatinus |
528 |
645 |
797 |
870 |
410 |
410 |
410 |
D7473 |
Removal of torus mandibularis |
525 |
643 |
790 |
832 |
408 |
408 |
408 |
D7485 |
Surg reduct of osseous tuberos |
474 |
576 |
712 |
812 |
367 |
367 |
367 |
D7490 |
Resection, mandible-bone graft |
5945 |
5945 |
7941 |
8552 |
5382 |
4072 |
4072 |
D7510 |
Incision/drainage,abscess-intr |
162 |
198 |
247 |
285 |
126 |
126 |
126 |
D7511 |
I&D intraoral sft tiss. compl. |
220 |
270 |
337 |
390 |
222 |
172 |
172 |
D7520 |
Incision/drainage,abscess-extr |
269 |
331 |
408 |
472 |
240 |
241 |
241 |
D7521 |
I&D extraoral sft tiss compli. |
350 |
424 |
524 |
588 |
400 |
324 |
324 |
D7530 |
Removal of foreign body/skin |
251 |
290 |
371 |
408 |
241 |
195 |
195 |
D7540 |
Removal-musculoskeletal system |
467 |
531 |
678 |
746 |
362 |
364 |
364 |
D7550 |
Part. stectomy/sequestrectomy |
368 |
440 |
523 |
588 |
300 |
301 |
301 |
D7560 |
Max. sinusotomy - removal |
810 |
992 |
1225 |
1374 |
734 |
630 |
630 |
D7610 |
Maxilla - open reduction |
3045 |
3735 |
4505 |
4956 |
2861 |
2369 |
2369 |
D7620 |
Maxilla - closed reduction |
2413 |
2957 |
3475 |
3912 |
2253 |
1876 |
1876 |
D7630 |
Mandible - open reduction |
3048 |
3737 |
4611 |
5166 |
2905 |
2372 |
2372 |
D7640 |
Mandible - closed reduction |
2352 |
2886 |
3559 |
3959 |
2221 |
1832 |
1832 |
D7650 |
Malar/zygo arch - open reduct |
2739 |
3362 |
3983 |
4381 |
2522 |
2132 |
2132 |
D7660 |
Malar/zygo arch -closed reduct |
2253 |
2764 |
3343 |
3677 |
2102 |
1755 |
1755 |
D7670 |
Alveolus - closed reduction |
961 |
1172 |
1446 |
1473 |
882 |
745 |
745 |
D7671 |
Alveolus - open reduction |
607 |
744 |
916 |
1028 |
681 |
472 |
472 |
D7680 |
Facial bones-complicatd reduct |
4565 |
5601 |
6910 |
7741 |
4294 |
3553 |
3553 |
D7710 |
Maxilla - open reduction |
3175 |
3894 |
4607 |
5067 |
3071 |
2470 |
2470 |
D7720 |
Maxilla - closed reduction |
2372 |
2910 |
3552 |
3907 |
2306 |
1846 |
1846 |
D7730 |
Mandible - open reduction |
3364 |
4125 |
5088 |
5702 |
3146 |
2616 |
2616 |
D7740 |
Mandible - closed reduction |
2535 |
3107 |
3700 |
4070 |
2408 |
1971 |
1971 |
D7750 |
Malar/zygo arch - open reduct |
2895 |
3551 |
4282 |
4711 |
2820 |
2254 |
2254 |
D7760 |
Malar/zygo arch -closed reduct |
3357 |
4116 |
5077 |
5690 |
3210 |
2612 |
2612 |
D7770 |
Alveolus - open reduction |
1892 |
2321 |
2843 |
3127 |
1798 |
1472 |
1472 |
D7771 |
Alveolus - closed reduction |
1189 |
1458 |
1798 |
2014 |
1154 |
926 |
926 |
D7780 |
Facial bones-complicatd reduct |
5655 |
6936 |
8558 |
9520 |
5390 |
4400 |
4400 |
D7810 |
Open reduction of dislocation |
2983 |
3659 |
4513 |
5001 |
2815 |
2321 |
2321 |
D7820 |
Closed reduction of dislocatio |
402 |
495 |
610 |
682 |
391 |
314 |
314 |
D7830 |
Manipulation under anesthesia |
536 |
656 |
809 |
907 |
544 |
418 |
418 |
D7840 |
Condylectomy |
3756 |
4605 |
5680 |
6258 |
3490 |
2922 |
2922 |
D7850 |
Surg discectomy w/ w/o implant |
3775 |
4631 |
5490 |
6039 |
3612 |
2938 |
2938 |
D7852 |
Disc repair |
3961 |
4860 |
5773 |
6350 |
3744 |
3084 |
3084 |
D7854 |
Synovectomy |
3911 |
4799 |
5702 |
6439 |
3651 |
3045 |
3045 |
D7856 |
Myotomy |
2473 |
3036 |
3699 |
4069 |
2351 |
1926 |
1926 |
D7858 |
Joint reconstruction |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7860 |
Arthrotomy |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7865 |
Arthroplasty |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7870 |
Arthrocentesls |
288 |
354 |
436 |
490 |
301 |
223 |
223 |
D7871 |
Non-arthroscopic lysis, lavage |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7872 |
Arthroscopy-diag w/ w/o biopsy |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7873 |
Arthroscopy-surg:lavage,lysis |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7874 |
Arthroscopy-surg:disc repositn |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7875 |
Arthroscopy - surg:synovectomy |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7876 |
Arthroscopy - surg:discectomy |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7877 |
Arthroscopy - surg:debridement |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7880 |
Occlusal orthotic device |
662 |
869 |
946 |
1040 |
618 |
662 |
662 |
D7881 |
Occlusal orthotic device adjustment |
152 |
190 |
233 |
364 |
141 |
119 |
119 |
D7899 |
Unspecified TMD therapy |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7910 |
Suture of recent small wounds |
212 |
257 |
316 |
347 |
160 |
161 |
161 |
D7911 |
Complicated suture - up to 5cm |
326 |
384 |
505 |
556 |
305 |
263 |
263 |
D7912 |
Complicated suture - > 5cm |
473 |
575 |
709 |
824 |
481 |
366 |
366 |
D7915 |
Other Repair Procedures |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7920 |
Skin Graft |
1704 |
2091 |
2578 |
2888 |
1725 |
1328 |
1328 |
D7921 |
Col/app of Autologous bld conc (PRP) |
513 |
513 |
513 |
513 |
513 |
513 |
513 |
D7940 |
Osteoplasty-orthognath deforms |
2579 |
3165 |
3905 |
4375 |
2517 |
2007 |
2007 |
D7941 |
Osteotomy - mandibular rami |
6637 |
8141 |
9414 |
10355 |
6138 |
5163 |
5163 |
D7943 |
Osteotomy - mand rami w/ graft |
6637 |
7492 |
8732 |
9605 |
5733 |
4753 |
4753 |
D7944 |
Osteotomy - segment/subapical |
4925 |
6044 |
7142 |
7856 |
4719 |
3835 |
3835 |
D7945 |
Osteotomy - body of mandible |
5008 |
6146 |
7429 |
8244 |
4650 |
3896 |
3896 |
D7946 |
LeFort I - max. total |
5907 |
7247 |
8940 |
9957 |
5457 |
4598 |
4598 |
D7947 |
LeFort I - max. segmented |
6148 |
7541 |
9100 |
10010 |
5751 |
4785 |
4785 |
D7948 |
LeFort II/III - w/o bone graft |
7008 |
8595 |
10438 |
11506 |
6580 |
5454 |
5454 |
D7949 |
LeFort II/III - w/ bone graft |
8237 |
10052 |
11920 |
12630 |
7493 |
6378 |
6378 |
D7950 |
Oss.,ost., or cart graft, mand |
1845 |
1845 |
2588 |
2847 |
1756 |
1667 |
1667 |
D7951 |
Sinus Aug. w/bone or sub. |
1713 |
2092 |
2980 |
3133 |
2106 |
1328 |
1328 |
D7952 |
Sinus Aug-vertical approach |
940 |
1122 |
1334 |
1467 |
667 |
702 |
702 |
D7953 |
Bone replcmt graft ridge site |
173 |
173 |
556 |
612 |
173 |
173 |
173 |
D7955 |
Repair - max. tissue defect |
2073 |
2402 |
2529 |
2782 |
1637 |
1645 |
1645 |
D7960 |
Frenulectomy - separate proc. |
324 |
395 |
471 |
518 |
240 |
251 |
251 |
D7963 |
Frenuloplasty |
356 |
436 |
530 |
598 |
328 |
276 |
276 |
D7970 |
Excision - hyperplastic tiss |
359 |
438 |
525 |
578 |
274 |
278 |
278 |
D7971 |
Excision - pericoronal gingiva |
169 |
208 |
274 |
311 |
132 |
132 |
132 |
D7972 |
Surg reduct, fibrs. tuberosity |
519 |
631 |
733 |
807 |
389 |
401 |
401 |
D7980 |
Sialolithotomy |
483 |
591 |
730 |
817 |
485 |
376 |
376 |
D7981 |
Excision of salivary gland |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7982 |
Sialodochoplasty |
1200 |
1474 |
1818 |
2004 |
1134 |
936 |
936 |
D7983 |
Closure of salivary fistula |
872 |
1072 |
1321 |
1481 |
865 |
681 |
681 |
D7990 |
Emergency tracheotomy |
906 |
1110 |
1370 |
1534 |
903 |
704 |
704 |
D7991 |
Coronoidectomy |
2784 |
3413 |
4151 |
4566 |
2645 |
2167 |
2167 |
D7995 |
Synthetic graft - mand/face |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7996 |
Impant-mand. - augmentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D7997 |
Appliance removal, w/ archbar |
197 |
241 |
305 |
407 |
200 |
154 |
154 |
D7998 |
Intraoral Plcmt Fixation Device Not in Conj. w/F |
1474 |
1806 |
2227 |
2496 |
1538 |
1147 |
1147 |
D7999 |
Unspecified oral surgery proc. |
132 |
154 |
210 |
220 |
106 |
106 |
106 |
D8010 |
Limited ortho - primary |
1395 |
1680 |
2255 |
2490 |
1015 |
1015 |
1015 |
D8010.6 |
Limited ortho - primary 6 Month Treatment |
0 |
705 |
1130 |
1245 |
705 |
0 |
0 |
D8010.C |
Limited ortho - primary 12 Month Treatment |
0 |
1200 |
2255 |
2490 |
1015 |
0 |
0 |
D8020 |
Limited ortho - transitional |
1490 |
2100 |
2510 |
2760 |
1015 |
1105 |
1105 |
D8020.6 |
Limited ortho - transitional 6 Month Treatment |
0 |
705 |
1260 |
1395 |
705 |
0 |
0 |
D8020.C |
Limited ortho - transitional 12 Month Treatmen |
0 |
1200 |
2515 |
2785 |
1015 |
0 |
0 |
D8030 |
Limited ortho - adolescent |
1785 |
2185 |
2920 |
3210 |
1015 |
1305 |
1305 |
D8030.6 |
Limited ortho - adolescent 6 Month Treatment |
0 |
705 |
1460 |
1615 |
705 |
0 |
0 |
D8030.C |
Limited ortho - adolescent 12 Month Treatmen |
0 |
1200 |
2925 |
3230 |
1015 |
0 |
0 |
D8040 |
Limited ortho - adult |
1785 |
2310 |
3140 |
3475 |
1015 |
1320 |
1320 |
D8040.6 |
Limited ortho - adult 6 Month Treatment |
0 |
910 |
1575 |
1735 |
910 |
0 |
0 |
D8040.C |
Limited ortho - adult 12 Month Treatment |
0 |
1500 |
3140 |
3475 |
1015 |
0 |
0 |
D8050 |
Interceptive ortho - primary |
1680 |
1680 |
2595 |
2865 |
1335 |
1305 |
1305 |
D8060 |
Interceptive ortho-transitionl |
1965 |
2100 |
2740 |
3030 |
1495 |
1455 |
1455 |
D8060.1 |
Reduced transitional orthodontics |
340 |
340 |
99999 |
99999 |
99999 |
99999 |
99999 |
D8070 |
Comprehensive ortho-transition |
3720 |
3720 |
5255 |
5805 |
3710 |
3080 |
3050 |
D8070.3 |
Bands Placed |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8080 |
Comprehensive ortho - adolesce |
3720 |
3720 |
5460 |
6005 |
3500 |
3135 |
3095 |
D8080.3 |
Bands placed |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8080.4 |
Active treatment complete |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8090 |
Comprehensive ortho - adult |
4175 |
4175 |
5455 |
6025 |
3870 |
3315 |
3275 |
D8090.3 |
Bands placed |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8090.4 |
Active treatment complete |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8090.5 |
Comprehensive ortho - adult Extensive Treatme |
0 |
4875 |
7130 |
8175 |
4260 |
0 |
0 |
D8210 |
Removable appliance therapy |
620 |
745 |
885 |
980 |
470 |
460 |
460 |
D8220 |
Fixed appliance therapy |
705 |
865 |
995 |
1095 |
515 |
535 |
535 |
D8660 |
Pre-ortho Treatment Visit (Records) |
318 |
318 |
461 |
651 |
318 |
318 |
318 |
D8660.1 |
Pedo/Ortho Screening Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8660.2 |
Ortho Screening Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8660.3 |
Ortho Tx Plan Presentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8660.4 |
Ortho/OS Case Conference |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8670 |
Periodic ortho treatment visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8680 |
Orthodontic retention |
0 |
0 |
495 |
545 |
240 |
0 |
0 |
D8681 |
Removable orthodontic retainer adjustment |
152 |
190 |
233 |
364 |
141 |
119 |
119 |
D8690 |
Orthodontic treatment |
0 |
0 |
290 |
320 |
150 |
0 |
0 |
D8691 |
Repair of ortho appliance |
155 |
190 |
225 |
250 |
145 |
125 |
125 |
D8692 |
Replace - lost/broken retainer |
225 |
225 |
330 |
360 |
170 |
210 |
210 |
D8692.1 |
Replace lost/broken ESSIX |
105 |
105 |
135 |
0 |
0 |
55 |
55 |
D8693 |
Rebond.,recem.,rep.,fixed ret |
155 |
160 |
325 |
360 |
170 |
125 |
125 |
D8694 |
Repair of fixed retainers, includes reattachment |
152 |
190 |
206 |
227 |
141 |
119 |
119 |
D8999 |
Unspecified ortho procedure |
0 |
0 |
148 |
164 |
70 |
0 |
0 |
D8999.1 |
Copyplast/ESSIX retainer,vac. fab. |
0 |
103 |
132 |
169 |
68 |
68 |
68 |
D8999.3 |
Ceramic bracket surcharge |
0 |
264 |
270 |
270 |
223 |
223 |
223 |
D8999.4 |
Invisalign in add to comp adult ortho |
0 |
908 |
0 |
0 |
0 |
0 |
0 |
D8999.5 |
Harmony in add to comp ortho |
1739 |
1739 |
1689 |
1689 |
1739 |
1739 |
1739 |
D8999.6 |
Herbst Appl Lab Cost |
0 |
360 |
496 |
538 |
255 |
255 |
255 |
D8999.7 |
Presurgical Ortho DX |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D8999.8 |
Spring Aligner |
235 |
235 |
322 |
322 |
213 |
213 |
213 |
D8999.9 |
Ortho TADS (mini-implant screws) |
0 |
156 |
0 |
0 |
0 |
0 |
0 |
D8999.B |
Rebanding |
223 |
223 |
215 |
99999 |
99999 |
99999 |
99999 |
D9110 |
Palliative Tx of dental pain |
86 |
106 |
129 |
150 |
68 |
68 |
68 |
D9120 |
Sectioning of FPD |
186 |
224 |
230 |
253 |
158 |
138 |
138 |
D9210 |
Local anesthesia - w/o surg |
0 |
0 |
0 |
0 |
36 |
0 |
0 |
D9211 |
Regional block anesthesia |
71 |
85 |
96 |
106 |
64 |
53 |
50 |
D9212 |
Trigeminal division block anes |
197 |
241 |
266 |
292 |
185 |
154 |
154 |
D9215 |
Local anesthesia w/ surg proc |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9219 |
Evaluation for deep sedation or general anesthe |
94 |
94 |
94 |
104 |
342 |
343 |
343 |
D9223 |
Deep sedation/general anesthesia – each 15 mi |
172 |
172 |
209 |
236 |
172 |
172 |
172 |
D9230 |
Analg, anxiolysis, inhal of NO |
72 |
72 |
80 |
86 |
71 |
72 |
72 |
D9241.1 |
Interv sedate/analg - sedation experience |
99999 |
0 |
99999 |
99999 |
50000 |
99999 |
99999 |
D9241.2 |
Interv sedate/analg - sedation assist |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9241.3 |
IV -Sedation Appt canceled |
99999 |
0 |
99999 |
99999 |
50000 |
99999 |
99999 |
D9243 |
Intravenous mod (conscious) sedation/analgesi |
100 |
100 |
200 |
236 |
172 |
172 |
172 |
D9248 |
Non-intrav conscious sedation |
231 |
231 |
231 |
235 |
216 |
226 |
226 |
D9248.1 |
Non-interv conscious sedation - sedation experi |
99999 |
0 |
99999 |
99999 |
50000 |
99999 |
99999 |
D9248.2 |
Non-interv conscious sedation - sedation assist |
99999 |
0 |
99999 |
99999 |
50000 |
99999 |
99999 |
D9248.3 |
Non IV -Sedation Appt canceled |
99999 |
0 |
99999 |
99999 |
50000 |
99999 |
99999 |
D9310 |
Consultation |
84 |
105 |
136 |
150 |
64 |
64 |
64 |
D9410 |
House/ext. care facility call |
151 |
183 |
235 |
259 |
123 |
124 |
124 |
D9420 |
Hospital call |
0 |
0 |
0 |
0 |
148 |
0 |
0 |
D9430 |
Office visit -observation only |
50 |
64 |
81 |
89 |
47 |
41 |
40 |
D9430.1 |
Endo-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9430.2 |
Ortho-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9430.3 |
Oral Surg-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9430.4 |
Perio-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9430.5 |
Pedo-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9430.6 |
Prosth-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9430.7 |
Oper/Fixed-Off Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9440 |
Office visit - after hours |
118 |
146 |
179 |
201 |
90 |
90 |
90 |
D9450 |
Case presentation, Detailed & |
0 |
77 |
149 |
165 |
0 |
0 |
0 |
D9450.1 |
Endo, Case Presentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.2 |
Periodontal Treatment Plan Presentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.3 |
Fixed, Case Presentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.4 |
Removable, Case Presentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.5 |
Ortho Consult, Case Presentati |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.6 |
TPU Transfer Patient Update |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.7 |
TPW Treatment Plan Workup |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.8 |
Geriatric, Tx Planning |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9450.9 |
Implant, Case Presentation |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9610 |
Therap.drug inject, single adm |
71 |
85 |
107 |
119 |
53 |
69 |
53 |
D9612 |
Therp.drug inj, 2 or more admn |
116 |
144 |
175 |
178 |
117 |
89 |
89 |
D9630 |
Other drugs/medicaments |
29 |
33 |
33 |
37 |
29 |
25 |
25 |
D9910 |
Applicate desensitizing medica |
42 |
50 |
63 |
69 |
32 |
46 |
34 |
D9911 |
Applicate desens resin-per tth |
53 |
68 |
80 |
90 |
51 |
46 |
42 |
D9920 |
Behavior management |
89 |
110 |
135 |
137 |
87 |
72 |
72 |
D9930 |
Tx,complications-unusual circs |
100 |
121 |
139 |
153 |
93 |
77 |
77 |
D9932 |
Cleaning/inspection removable complete dentu |
49 |
49 |
54 |
62 |
34 |
34 |
34 |
D9933 |
Cleaning/inspection removable complete dentu |
49 |
49 |
54 |
62 |
34 |
34 |
34 |
D9934 |
Cleaning/inspection removable partial denture, |
49 |
49 |
54 |
62 |
34 |
34 |
34 |
D9935 |
Cleaning/inspection removable partial denture, |
49 |
49 |
54 |
62 |
34 |
34 |
34 |
D9940 |
Occlusal guard |
426 |
522 |
622 |
685 |
314 |
318 |
316 |
D9941 |
Fabrication of athl mouthguard |
167 |
205 |
252 |
288 |
124 |
124 |
124 |
D9941.1 |
Mold for Athletic Mouthguards |
41 |
41 |
41 |
41 |
41 |
41 |
41 |
D9942 |
Repair/reline Occl Guard |
166 |
203 |
252 |
284 |
161 |
125 |
122 |
D9943 |
Occlusal guard adjustment |
152 |
190 |
233 |
364 |
141 |
119 |
119 |
D9950 |
Occlusion analysis-mountd case |
237 |
288 |
357 |
363 |
223 |
176 |
176 |
D9951 |
Occlusal adjustment - limited |
121 |
150 |
194 |
213 |
90 |
91 |
90 |
D9952 |
Occlusal adjustment - complete |
484 |
590 |
721 |
793 |
358 |
358 |
358 |
D9970 |
Enamel microabrasion |
150 |
182 |
214 |
230 |
140 |
111 |
111 |
D9971 |
Odontoplasty 1-2 teeth |
118 |
146 |
180 |
198 |
112 |
86 |
86 |
D9972 |
In-office External bleaching - per arch |
219 |
269 |
314 |
345 |
201 |
163 |
162 |
D9972.1 |
In-office One Hour Bleaching per arch |
338 |
442 |
544 |
555 |
305 |
268 |
268 |
D9973 |
In-office External bleaching - per tooth |
170 |
209 |
230 |
253 |
152 |
125 |
125 |
D9974 |
Internal bleaching - per tooth |
201 |
247 |
301 |
331 |
192 |
150 |
150 |
D9975 |
At home External bleaching per arch |
219 |
262 |
262 |
288 |
201 |
163 |
162 |
D9986 |
Missed appointment |
37 |
0 |
47 |
52 |
0 |
0 |
0 |
D9987 |
Cancelled appointment |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
D9999 |
Unspecified adjunctive proc. |
63 |
72 |
94 |
104 |
49 |
49 |
49 |
D9999.1 |
No Charge Office Visit |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
DCMP10 |
Soft Tissue Exam Competency |
0 |
0 |
0 |
0 |
0 |
0 |
0 |
E0486 |
Oral Device/Appliance Custom Fab |
1900 |
99999 |
2950 |
2950 |
99999 |
99999 |
99999 |
E0486.1 |
Oral Device/Appliance - TAP |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E0486.2 |
Oral Device/ Appl Custom Fab-AGD |
1305 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E0486.3 |
Oral Device/Appliance Custom Fab - Faculty |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E1001 |
Gold |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E1002 |
Amalgam |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E1003 |
Composite |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E1004 |
Miscellaneous Metallic |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E1005 |
Porcelain |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
E1006 |
Sedative |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M10180 |
Wound I & D |
448 |
448 |
597 |
657 |
99999 |
99999 |
99999 |
M11000 |
Debridement Eczematous or Infe |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M11012 |
Debridement-skin,subcutaneous |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M11100 |
Biopsy of skin,subcutaneous ti |
131 |
131 |
174 |
191 |
99999 |
99999 |
99999 |
M11900 |
Intralesional lesion<> |
67 |
67 |
71 |
75 |
99999 |
99999 |
99999 |
M11901 |
Intralesional>> |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M12001 |
Simple repair of superficial w |
98 |
98 |
104 |
108 |
99999 |
99999 |
99999 |
M12002 |
Simple repair;2.6 cm to 7.5 cm |
98 |
98 |
104 |
108 |
99999 |
99999 |
99999 |
M12004 |
Simple repair;7.6 to 12.5 cm |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M12005 |
Simple repair;12.6 to 20.0 cm |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M12011 |
Simple repair;2.5 cm or less |
308 |
308 |
411 |
451 |
99999 |
99999 |
99999 |
M12013 |
Simple repair;2.6 to 5.0 cm |
330 |
330 |
442 |
485 |
99999 |
99999 |
99999 |
M12014 |
Simple repair;5.1 to 7.5 cm |
398 |
398 |
531 |
584 |
99999 |
99999 |
99999 |
M12015 |
Simple repair;7.6 to 12.5 cm |
498 |
498 |
664 |
731 |
99999 |
99999 |
99999 |
M12017 |
Simple Repair Wounds:20.1 CM |
738 |
738 |
984 |
1082 |
99999 |
99999 |
99999 |
M12018 |
Simple repair;over 30.0 cm |
810 |
810 |
1081 |
1189 |
99999 |
99999 |
99999 |
M12020 |
Simple repair;over 30.0 cm |
374 |
374 |
499 |
549 |
99999 |
99999 |
99999 |
M12031 |
Layer Closure;2.5 cm or less |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M12034 |
Layer Closure of Wounds:7.6CM |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M12051 |
Layer Closure;2.5 cm or less |
365 |
365 |
487 |
535 |
99999 |
99999 |
99999 |
M12052 |
Layer Closure;2.6 to 5.0 cm |
407 |
407 |
542 |
597 |
99999 |
99999 |
99999 |
M12053 |
Layer Closure;5.1 to 7.5 cm |
496 |
496 |
661 |
727 |
99999 |
99999 |
99999 |
M12054 |
Layer Closure;7.6 to 12.5 cm |
615 |
615 |
820 |
903 |
99999 |
99999 |
99999 |
M12055 |
Layer Closure;12.6 to 20.0 cm |
778 |
778 |
1039 |
1142 |
99999 |
99999 |
99999 |
M13120 |
Repair,comp.,scalp;1.1to 2.5 |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M13121 |
Repair,comp.,scalp,2.6to7.5 |
608 |
608 |
810 |
891 |
99999 |
99999 |
99999 |
M13122 |
Repair,comp.,scalp,add 5/les |
255 |
255 |
340 |
374 |
99999 |
99999 |
99999 |
M13131 |
Repair,comp.,mouth,1.1to2.5 |
481 |
481 |
642 |
705 |
99999 |
99999 |
99999 |
M13132 |
Repair,comp.,mouth, 2.6to7.5 c |
790 |
790 |
1055 |
1160 |
99999 |
99999 |
99999 |
M13133 |
Repair,comp.,mouth, add 5/less |
342 |
342 |
456 |
501 |
99999 |
99999 |
99999 |
M13150 |
Repair,comp.,lips, 1.0/less |
533 |
533 |
711 |
782 |
99999 |
99999 |
99999 |
M13151 |
Repair,comp.,lips,1.1to2.5 cm |
621 |
621 |
828 |
911 |
99999 |
99999 |
99999 |
M13152 |
Repair,comp.,lips,2.6to7.5 cm |
1062 |
1062 |
1417 |
1559 |
99999 |
99999 |
99999 |
M13153 |
Repair,comp.,lips,add 5/less |
360 |
360 |
480 |
529 |
99999 |
99999 |
99999 |
M15240 |
Full thick graft,20 sq cm/less |
1554 |
1554 |
2072 |
2279 |
99999 |
99999 |
99999 |
M15820 |
Blepharoplasty,Lower Eyelid |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M17000 |
Destruction lesion,first lesio |
95 |
95 |
126 |
139 |
99999 |
99999 |
99999 |
M20000 |
Musculoskeletal System (incisi |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M20220 |
Biopsy; superficial |
368 |
368 |
492 |
540 |
99999 |
99999 |
99999 |
M20240 |
Biopsy,bone |
570 |
570 |
761 |
836 |
99999 |
99999 |
99999 |
M20550 |
Trigger Point Injection |
120 |
120 |
160 |
176 |
99999 |
99999 |
99999 |
M20605 |
Arthrocentesis aspiration |
122 |
122 |
165 |
180 |
99999 |
99999 |
99999 |
M20680 |
Removal of implant,deep |
954 |
954 |
1272 |
1401 |
99999 |
99999 |
99999 |
M20900 |
Bone graft,any,minor,small |
977 |
977 |
1303 |
1433 |
99999 |
99999 |
99999 |
M20926 |
Tissue grafts,other |
939 |
939 |
1253 |
1377 |
99999 |
99999 |
99999 |
M20999 |
Unlisted Procedure, musculoske |
99999 |
99999 |
511 |
520 |
99999 |
99999 |
99999 |
M21010 |
Arthrotomy,temporomandibular j |
2318 |
2318 |
3090 |
3400 |
99999 |
99999 |
99999 |
M21015 |
Radical tumor resect.,soft,fac |
1346 |
1346 |
1796 |
1974 |
99999 |
99999 |
99999 |
M21025 |
Excision of bone,mandible |
1582 |
1582 |
2108 |
2320 |
99999 |
99999 |
99999 |
M21030 |
Excision of Benign Tumor |
1223 |
1223 |
1630 |
1793 |
99999 |
99999 |
99999 |
M21031 |
Excision of torus mandibularis |
595 |
595 |
793 |
872 |
99999 |
99999 |
99999 |
M21040 |
Exc. benign cyst/tumor,mandibl |
1036 |
1036 |
1382 |
1520 |
99999 |
99999 |
99999 |
M21041 |
Exc. benign cy/tu,mand., compl |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M21050 |
Arthrectomy, TMJ; unilateral |
2703 |
2703 |
3602 |
3963 |
99999 |
99999 |
99999 |
M21070 |
Coronoidectomy;separate proc |
2160 |
2160 |
2878 |
3166 |
99999 |
99999 |
99999 |
M21079 |
Impression & Custom Prep;Inter |
3730 |
3730 |
4972 |
5469 |
99999 |
99999 |
99999 |
M21080 |
Definitive Obtruator Pros. |
4060 |
4060 |
5414 |
5955 |
99999 |
99999 |
99999 |
M21085 |
Impres/cust prep; o.s. splint |
1212 |
1212 |
1616 |
1778 |
99999 |
99999 |
99999 |
M21088 |
Impres&Cust Prep:Facial Pros |
1542 |
1752 |
2334 |
2569 |
50000 |
99999 |
99999 |
M21089 |
Unlisted Maxillofacial Prosthe |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
M21110 |
Interdental fixation device |
1198 |
1198 |
1598 |
1759 |
99999 |
99999 |
99999 |
M21120 |
Genioplasty,Augmentation |
1603 |
1603 |
2137 |
2351 |
99999 |
99999 |
99999 |
M21125 |
Augmentation,mand. body;prosth |
2545 |
2545 |
3394 |
3733 |
99999 |
99999 |
99999 |
M21139 |
Countoring & setback ant. Sinu |
3084 |
3084 |
4111 |
4523 |
99999 |
99999 |
99999 |
M21141 |
Reconstruct. midface, lefort I |
4483 |
4483 |
5979 |
6576 |
99999 |
99999 |
99999 |
M21142 |
Reconstruct. midface,lefort I |
4679 |
4679 |
6238 |
6862 |
99999 |
99999 |
99999 |
M21143 |
Reconstruc midface,lefort I |
4820 |
4820 |
6427 |
7069 |
99999 |
99999 |
99999 |
M21146 |
Reconstruct midface,lefort I |
4885 |
4885 |
6513 |
7165 |
99999 |
99999 |
99999 |
M21147 |
Reconstruct Midface Lefort 1 |
5587 |
5587 |
7451 |
8195 |
99999 |
99999 |
99999 |
M21188 |
Reconstruct Midface Osteotomie |
5046 |
5046 |
6729 |
7402 |
99999 |
99999 |
99999 |
M21193 |
Reconstruct of MandibularRamus |
4131 |
4131 |
5508 |
6058 |
99999 |
99999 |
99999 |
M21195 |
Reconstruct mand ramus,sagitt |
4502 |
4502 |
6003 |
6603 |
99999 |
99999 |
99999 |
M21196 |
Reconstruct mand. ramus sagitt |
4675 |
4675 |
6233 |
6856 |
99999 |
99999 |
99999 |
M21209 |
Osteoplasty,facial bones,reduc |
1779 |
1779 |
2372 |
2610 |
99999 |
99999 |
99999 |
M21210 |
Graft,Bone:Nasal,Maxillary & |
3122 |
3122 |
4163 |
4579 |
99999 |
99999 |
99999 |
M21215 |
Graft, bone, mandible |
3258 |
3258 |
4344 |
4779 |
99999 |
99999 |
99999 |
M21235 |
Graft,Ear Cartilage,Autograft, |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M21240 |
Arthroplasty, TMJ; autograft |
3937 |
3937 |
5248 |
5773 |
99999 |
99999 |
99999 |
M21248 |
Reconstruct mx/md,endosteal im |
3339 |
3339 |
4454 |
4898 |
99999 |
99999 |
99999 |
M21249 |
Reconstruct mx/md,endosteal im |
4882 |
4882 |
6509 |
7160 |
99999 |
99999 |
99999 |
M21299 |
Unlisted craniofacial procedur |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
M21315 |
Manipulative tx, nasal bone fr |
448 |
448 |
597 |
657 |
99999 |
99999 |
99999 |
M21320 |
Manipulative tx, nasal bone fr |
716 |
716 |
955 |
1052 |
99999 |
99999 |
99999 |
M21325 |
Open Treatment of Nasal Fractu |
1156 |
1156 |
1542 |
1695 |
99999 |
99999 |
99999 |
M21336 |
Open tx, nasal fx, stabilizati |
1420 |
1420 |
1894 |
2083 |
99999 |
99999 |
99999 |
M21338 |
Open tx, nasoethmoid fracture |
1921 |
1921 |
2561 |
2817 |
99999 |
99999 |
99999 |
M21339 |
Open tx, nasoethmoid fracture |
2238 |
2238 |
2983 |
3281 |
99999 |
99999 |
99999 |
M21344 |
Open tx, comp. front sinus fra |
3693 |
3693 |
4924 |
5416 |
99999 |
99999 |
99999 |
M21346 |
Open Treatment Nasomaxillary |
3090 |
3090 |
4122 |
4534 |
99999 |
99999 |
99999 |
M21356 |
Open tx, depressed zygomatic a |
1358 |
1358 |
1810 |
1993 |
99999 |
99999 |
99999 |
M21360 |
Open tx,closed/open malar frac |
1709 |
1709 |
2279 |
2506 |
99999 |
99999 |
99999 |
M21365 |
Open tx,closed/open comp malar |
3170 |
3170 |
4228 |
4650 |
99999 |
99999 |
99999 |
M21366 |
Open tx, comp frac malar,bone |
3391 |
3391 |
4521 |
4973 |
99999 |
99999 |
99999 |
M21386 |
Open tx, orbital floor blowout |
2365 |
2365 |
3155 |
3471 |
99999 |
99999 |
99999 |
M21390 |
Open tx, orbital blowout fract |
2948 |
2948 |
3931 |
4323 |
99999 |
99999 |
99999 |
M21406 |
Open tx, fracture orbit w/o bl |
2142 |
2142 |
2857 |
3142 |
99999 |
99999 |
99999 |
M21421 |
Palatal or Alveolar Ridge Frac |
1851 |
1851 |
2468 |
2715 |
99999 |
99999 |
99999 |
M21422 |
Open tx, palatal/alveo ridge f |
2254 |
2254 |
3005 |
3306 |
99999 |
99999 |
99999 |
M21423 |
Open tx, palatal mx fracture |
2585 |
2585 |
3447 |
3793 |
99999 |
99999 |
99999 |
M21433 |
Open tx, craniofacial separati |
4553 |
4553 |
6071 |
6678 |
99999 |
99999 |
99999 |
M21435 |
Complicated, fixation by head |
4144 |
4144 |
5525 |
6079 |
99999 |
99999 |
99999 |
M21440 |
Manipulative tx alveolar ridge |
1227 |
1227 |
1635 |
1800 |
99999 |
99999 |
99999 |
M21451 |
Closed/open md fracture |
1648 |
1648 |
2199 |
2419 |
99999 |
99999 |
99999 |
M21453 |
Open Mandibular Fracture/Manip |
1827 |
1827 |
2434 |
2678 |
99999 |
99999 |
99999 |
M21454 |
Open tx closed/open md fractur |
2112 |
2112 |
2817 |
3098 |
99999 |
99999 |
99999 |
M21461 |
Open tx, closed/open md fractu |
2896 |
2896 |
3862 |
4248 |
99999 |
99999 |
99999 |
M21462 |
Open tx, closed/open md frac |
3162 |
3162 |
4217 |
4638 |
99999 |
99999 |
99999 |
M21470 |
Open tx, comp closed/open md |
3927 |
3927 |
5236 |
5759 |
99999 |
99999 |
99999 |
M21480 |
Uncomplicated treatment of TMJ |
228 |
228 |
304 |
335 |
99999 |
99999 |
99999 |
M21499 |
Unlisted musculoskeletal proce |
99999 |
99999 |
477 |
516 |
99999 |
99999 |
99999 |
M21555 |
Excision benign tumor;subcutan |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M29804 |
Arthroscopy TMJ; surgical |
2333 |
2333 |
3112 |
3422 |
99999 |
99999 |
99999 |
M30000 |
Respiratory System (drainag |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M30580 |
Repair fistula;oromaxillary |
1392 |
1392 |
1855 |
2041 |
99999 |
99999 |
99999 |
M31020 |
Sinusotomy,mx,intranasal |
674 |
674 |
899 |
988 |
99999 |
99999 |
99999 |
M31030 |
Sinusotomy mx,intranasal radic |
1564 |
1564 |
2086 |
2294 |
99999 |
99999 |
99999 |
M40000 |
Digestive System |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M40490 |
Biopsy of lip |
173 |
173 |
231 |
254 |
99999 |
99999 |
99999 |
M40510 |
Excision Lip/closure |
1219 |
1219 |
1625 |
1787 |
99999 |
99999 |
99999 |
M40800 |
Drainage of abscess,cyst,hemat |
267 |
267 |
355 |
391 |
99999 |
99999 |
99999 |
M40801 |
Drainage Abscess,Cyst,Hematoma |
520 |
520 |
693 |
763 |
99999 |
99999 |
99999 |
M40804 |
Removal of embedded foreign bo |
292 |
292 |
391 |
429 |
99999 |
99999 |
99999 |
M40808 |
Biopsy,vestibule of mouth |
271 |
271 |
362 |
398 |
99999 |
99999 |
99999 |
M40810 |
Excision of lesion of mucosa/s |
300 |
300 |
400 |
441 |
99999 |
99999 |
99999 |
M40812 |
Excision, vestibule closure |
394 |
394 |
525 |
578 |
99999 |
99999 |
99999 |
M40814 |
Excision lesion of mucosa/subm |
674 |
674 |
899 |
988 |
99999 |
99999 |
99999 |
M40816 |
Complex exc. Of muscle |
787 |
787 |
1050 |
1155 |
99999 |
99999 |
99999 |
M40818 |
Exc.mucosa,vest.donor |
537 |
537 |
716 |
788 |
99999 |
99999 |
99999 |
M40819 |
Exc. Frenum,lab.or buc. |
442 |
442 |
589 |
648 |
99999 |
99999 |
99999 |
M40820 |
Destruction of lesion or scar |
351 |
351 |
467 |
515 |
99999 |
99999 |
99999 |
M40830 |
Closure of laceration,vestibul |
342 |
342 |
456 |
501 |
99999 |
99999 |
99999 |
M40831 |
Closure laceration,vestibule m |
473 |
473 |
631 |
695 |
99999 |
99999 |
99999 |
M41000 |
Intraoral incision/drainage to |
248 |
248 |
329 |
363 |
99999 |
99999 |
99999 |
M41005 |
Intraoral incision/drainage to |
302 |
302 |
403 |
444 |
99999 |
99999 |
99999 |
M41007 |
Intraoral incision/drainage to |
591 |
591 |
789 |
869 |
99999 |
99999 |
99999 |
M41008 |
Intraoral incision/drainage to |
588 |
588 |
784 |
863 |
99999 |
99999 |
99999 |
M41009 |
Intraoral incision/drainage to |
687 |
687 |
914 |
1007 |
99999 |
99999 |
99999 |
M41016 |
Extraoral Incision & Drainage |
677 |
677 |
902 |
991 |
99999 |
99999 |
99999 |
M41017 |
Extraoral incision/drainage fl |
716 |
716 |
955 |
1052 |
99999 |
99999 |
99999 |
M41100 |
Biopsy tongue;anterior 2/3 |
283 |
283 |
376 |
414 |
99999 |
99999 |
99999 |
M41105 |
Biopsy tongue;post 1/3 |
291 |
291 |
390 |
428 |
99999 |
99999 |
99999 |
M41108 |
Biopsy floor of mouth |
244 |
244 |
324 |
357 |
99999 |
99999 |
99999 |
M41110 |
Excision of Lession of Tougue |
328 |
328 |
438 |
482 |
99999 |
99999 |
99999 |
M41112 |
Excision,ant 2/3 closoure |
556 |
556 |
741 |
816 |
99999 |
99999 |
99999 |
M41113 |
Excision, post. 1/3 closure |
671 |
671 |
894 |
983 |
99999 |
99999 |
99999 |
M41116 |
Excision, Lesion flloor Mouth |
611 |
611 |
816 |
898 |
99999 |
99999 |
99999 |
M41250 |
Repair laceration 2.5 cm/less |
366 |
366 |
490 |
538 |
99999 |
99999 |
99999 |
M41252 |
Repair Laceration Tongue,Floor |
699 |
699 |
932 |
1024 |
99999 |
99999 |
99999 |
M41520 |
Frenuloplasty |
585 |
585 |
781 |
858 |
99999 |
99999 |
99999 |
M41805 |
Remov of Foreign body, soft ti |
287 |
287 |
384 |
422 |
99999 |
99999 |
99999 |
M41806 |
Remov of Foreign body, bone |
397 |
397 |
529 |
582 |
99999 |
99999 |
99999 |
M41820 |
Gingivectomy,excision gingiva |
502 |
502 |
669 |
737 |
99999 |
99999 |
99999 |
M41821 |
Operculectomy,exc.pericoronal |
124 |
124 |
166 |
181 |
99999 |
99999 |
99999 |
M41822 |
Excision of fibrous tuberositi |
350 |
350 |
465 |
513 |
99999 |
99999 |
99999 |
M41823 |
Excision of osseous tuberositi |
620 |
620 |
826 |
909 |
99999 |
99999 |
99999 |
M41825 |
Excision, alveolus closure |
342 |
342 |
456 |
501 |
99999 |
99999 |
99999 |
M41826 |
Excision, alveolus closure |
497 |
497 |
663 |
730 |
99999 |
99999 |
99999 |
M41828 |
Excision hyperplastic alveo mu |
600 |
600 |
798 |
878 |
99999 |
99999 |
99999 |
M41830 |
Alveol.Incl Curr. Of Osteitis |
567 |
567 |
755 |
831 |
99999 |
99999 |
99999 |
M41850 |
Destruction of lesion,dentoalv |
247 |
247 |
328 |
362 |
99999 |
99999 |
99999 |
M41870 |
Periodontal mucosal grafting |
617 |
617 |
822 |
905 |
99999 |
99999 |
99999 |
M41872 |
Gingivoplasty,each quadrant |
693 |
693 |
923 |
1016 |
99999 |
99999 |
99999 |
M41874 |
Alveoplasty |
630 |
630 |
841 |
925 |
99999 |
99999 |
99999 |
M41899 |
Unspecified proc., dentoalveol |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
M42000 |
Drain abscess of palate |
293 |
293 |
392 |
431 |
99999 |
99999 |
99999 |
M42100 |
Biopsy of palate, uvula |
277 |
277 |
368 |
406 |
99999 |
99999 |
99999 |
M42104 |
Excision, palate |
378 |
378 |
504 |
556 |
99999 |
99999 |
99999 |
M42106 |
Excision, palate closure |
476 |
476 |
633 |
697 |
99999 |
99999 |
99999 |
M42107 |
Excision lesion platale w/loca |
1041 |
1041 |
1387 |
1526 |
99999 |
99999 |
99999 |
M42160 |
Destruction of lesion, palate |
399 |
399 |
533 |
585 |
99999 |
99999 |
99999 |
M42180 |
Repair laceration palate up to |
424 |
424 |
566 |
622 |
99999 |
99999 |
99999 |
M42210 |
Palatoplasty cleft palate w/bo |
3438 |
3438 |
4582 |
5041 |
99999 |
99999 |
99999 |
M42310 |
Drain of absc.sub max or subli |
311 |
311 |
413 |
455 |
99999 |
99999 |
99999 |
M42325 |
Fistulization of subling. Sali |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M42330 |
Sumbandibular,sublingual or |
413 |
413 |
550 |
606 |
99999 |
99999 |
99999 |
M42720 |
Incision/drain abs;intraoral |
731 |
731 |
974 |
1071 |
99999 |
99999 |
99999 |
M60000 |
Thyroglossal I & D |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M64400 |
Trigeminal Anesthesia |
258 |
258 |
345 |
379 |
99999 |
99999 |
99999 |
M64550 |
Application of surface neurost |
46 |
46 |
64 |
69 |
99999 |
99999 |
99999 |
M64722 |
Decompression;unspec. nerve |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M65000 |
Eye and Ocular Adnexa |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M67914 |
Repair of Extropion;suture |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M70000 |
Diagnostic Radiology |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M70100 |
Panogram, mandible |
25 |
25 |
32 |
35 |
99999 |
99999 |
99999 |
M70140 |
Radiograph, facial bones |
98 |
98 |
104 |
112 |
99999 |
99999 |
99999 |
M70250 |
Skull, less than 4 views |
33 |
33 |
43 |
47 |
99999 |
99999 |
99999 |
M70300 |
Radiologic exam, teeth;single view |
12 |
12 |
16 |
16 |
99999 |
99999 |
99999 |
M70310 |
Radiologic exam;teeth,partial |
12 |
12 |
13 |
15 |
99999 |
99999 |
99999 |
M70320 |
Radiologic exam, complete, full mouth |
100 |
100 |
100 |
100 |
99999 |
99999 |
99999 |
M70328 |
Radio,Exam,TMJ, open&clsd unil |
26 |
26 |
33 |
36 |
99999 |
99999 |
99999 |
M70330 |
Radio.,Exam,TMJ,open&clsd bila |
33 |
33 |
43 |
47 |
99999 |
99999 |
99999 |
M70350 |
Cephalogram,Orthodontic |
99 |
99 |
99 |
99 |
99999 |
99999 |
99999 |
M70355 |
Orthopantogram (Panoramic) |
84 |
84 |
0 |
84 |
99999 |
99999 |
99999 |
M70380 |
Radiology Exam. Salivary |
23 |
23 |
30 |
33 |
99999 |
99999 |
99999 |
M76100 |
Radiological exam, single plan |
159 |
159 |
212 |
233 |
99999 |
99999 |
99999 |
M76101 |
Cross-sec. Oblique tomogram, i |
235 |
235 |
314 |
343 |
99999 |
99999 |
99999 |
M76140 |
Radiology Consult |
65 |
65 |
84 |
94 |
99999 |
99999 |
99999 |
M76175 |
Duplicate Films |
0 |
0 |
28 |
28 |
99999 |
99999 |
99999 |
M76449 |
Duplication/records |
0 |
0 |
69 |
69 |
99999 |
99999 |
99999 |
M76999 |
Unlisted Ultrasound Procedure |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M78300 |
Bone and/or joint imaging |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M80000 |
Pathologic Examination |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M87070 |
Culture, bacterial, any other |
49 |
49 |
68 |
74 |
99999 |
99999 |
99999 |
M87205 |
SMEAR,PRIMARY SOURCE W/INT. |
24 |
24 |
31 |
34 |
99999 |
99999 |
99999 |
M87210 |
Culture,bacterial screening on |
67 |
67 |
136 |
210 |
99999 |
99999 |
99999 |
M88304 |
Surgical Path, Gross & Microsc |
94 |
94 |
125 |
138 |
99999 |
99999 |
99999 |
M88305 |
Surgical Path., Gross & Micros |
161 |
161 |
215 |
237 |
99999 |
99999 |
99999 |
M88311 |
Decalcification Procedure |
33 |
33 |
43 |
47 |
99999 |
99999 |
99999 |
M90000 |
Evaluation and Management |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M90782 |
IV sympathetic Blockade |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M90784 |
Therapeutic/Diagnostic Injecti |
98 |
98 |
104 |
219 |
99999 |
99999 |
99999 |
M90792 |
Therapeutic/Diagnostic Injecti |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M90830 |
Review of Records |
55 |
55 |
66 |
67 |
99999 |
99999 |
99999 |
M90901 |
Biofeedback |
50 |
50 |
69 |
75 |
99999 |
99999 |
99999 |
M91480 |
Manipulation |
0 |
0 |
105 |
106 |
99999 |
99999 |
99999 |
M94762 |
Noninvasive Pulse Oximetry (Overnight monitor |
57 |
57 |
57 |
57 |
99999 |
99999 |
99999 |
M95868 |
Electromyography,bilateral |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M95999 |
Unspecified neurological |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
M96405 |
Intralesional Chemotherapy |
98 |
98 |
0 |
0 |
99999 |
99999 |
99999 |
M97026 |
Infrared |
0 |
0 |
39 |
39 |
99999 |
99999 |
99999 |
M97032 |
Application Of Modality To One |
35 |
35 |
46 |
50 |
99999 |
99999 |
99999 |
M97110 |
Physical medicine treatment |
62 |
62 |
81 |
90 |
99999 |
99999 |
99999 |
M97139 |
Unlisted procedure |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
99999 |
M97140 |
Manual Therapy |
0 |
0 |
55 |
55 |
99999 |
99999 |
99999 |
M97260 |
Refrigerant Spray/Stretch |
0 |
0 |
34 |
43 |
99999 |
99999 |
99999 |
M97265 |
Joint Mobilization |
0 |
0 |
69 |
69 |
99999 |
99999 |
99999 |
M97540 |
Train/Daily Living |
0 |
0 |
104 |
104 |
99999 |
99999 |
99999 |
M97780 |
Acupuncture |
0 |
0 |
97 |
97 |
99999 |
99999 |
99999 |
M97781 |
Acupuncture (E.S.) |
0 |
0 |
122 |
122 |
99999 |
99999 |
99999 |
M97799 |
Unlisted Procedure |
99999 |
99999 |
49 |
49 |
99999 |
99999 |
99999 |
M97810 |
Initial Acupuncture Therapy (W/O) stim |
0 |
0 |
55 |
55 |
99999 |
99999 |
99999 |
M97811 |
Acupuncture Therapy Addl 15 mins (W/O stim) |
0 |
0 |
29 |
29 |
99999 |
99999 |
99999 |
M97813 |
Initial Acupuncture Therapy (W stim) |
0 |
0 |
72 |
72 |
99999 |
99999 |
99999 |
M97814 |
Acupuncture Therapy Addl 15 mins (W/stim) |
0 |
0 |
33 |
33 |
99999 |
99999 |
99999 |
M99002 |
Adjustment |
27 |
27 |
34 |
38 |
99999 |
99999 |
99999 |
M99024 |
OV-Post OP |
45 |
45 |
69 |
89 |
99999 |
99999 |
99999 |
M99050 |
OV-after hrs-basic service |
58 |
58 |
77 |
84 |
99999 |
99999 |
99999 |
M99058 |
Office Emerg. Basis |
50 |
50 |
69 |
75 |
34 |
34 |
34 |
M99070 |
Supplies & Materials, Provided |
99999 |
99999 |
99999 |
99999 |
0 |
0 |
0 |
M99201 |
Office or outpatient visit |
69 |
69 |
92 |
100 |
45 |
45 |
45 |
M99202 |
Office or outpatient visit |
95 |
95 |
126 |
139 |
64 |
64 |
64 |
M99203 |
Office or outpatient visit |
145 |
145 |
193 |
213 |
97 |
97 |
97 |
M99204 |
Office or outpatient visit |
213 |
213 |
285 |
314 |
142 |
142 |
142 |
M99205 |
Office or outpatient visit |
278 |
278 |
370 |
407 |
185 |
185 |
185 |
M99211 |
Exam, Est. Pt. Brief |
37 |
37 |
48 |
53 |
25 |
25 |
25 |
M99212 |
Office or other outpatient visit |
58 |
58 |
101 |
101 |
39 |
39 |
39 |
M99213 |
Office or outpatient visit |
84 |
84 |
114 |
125 |
57 |
57 |
57 |
M99214 |
Exam, Est. Pt. Ext. |
129 |
129 |
171 |
188 |
84 |
84 |
84 |
M99215 |
Office or other ouptatient vis |
179 |
179 |
240 |
262 |
119 |
119 |
119 |
M99217 |
Observation care discharge |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M99218 |
Initial observation care |
124 |
124 |
166 |
181 |
99999 |
99999 |
99999 |
M99221 |
Initial hospital care |
153 |
153 |
205 |
224 |
99999 |
99999 |
99999 |
M99231 |
Subsequent hospital care |
73 |
73 |
97 |
107 |
99999 |
99999 |
99999 |
M99232 |
Subsequent hospital care |
107 |
107 |
142 |
156 |
99999 |
99999 |
99999 |
M99241 |
Office consultation |
94 |
94 |
124 |
136 |
99999 |
99999 |
99999 |
M99242 |
Office consultation |
152 |
152 |
203 |
222 |
99999 |
99999 |
99999 |
M99243 |
Office consultation |
197 |
197 |
262 |
289 |
99999 |
99999 |
99999 |
M99244 |
Comprehensive history consult |
279 |
279 |
371 |
408 |
99999 |
99999 |
99999 |
M99251 |
Initial inpatient consultation |
113 |
113 |
150 |
166 |
99999 |
99999 |
99999 |
M99252 |
Initial inpatient consultation |
180 |
180 |
242 |
265 |
99999 |
99999 |
99999 |
M99253 |
Initial inpatient consultation |
228 |
228 |
304 |
335 |
99999 |
99999 |
99999 |
M99254 |
Initial inpatient consultation |
280 |
280 |
372 |
409 |
99999 |
99999 |
99999 |
M99262 |
Consult, FollowUP In Pt. |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M99271 |
Confirming Cons. P. O. |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M99302 |
Eval./manage;nursing facility |
0 |
0 |
0 |
0 |
99999 |
99999 |
99999 |
M99401 |
Preventive Counseling |
65 |
65 |
84 |
94 |
99999 |
99999 |
99999 |
M99402 |
Preventive Counseling Expaned |
100 |
100 |
133 |
147 |
99999 |
99999 |
99999 |