Clinic Manual

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Subject:  Class III – Clinical – H. Patient Administration

Reviewed and/or Revised: 09/01/2017

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