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updated April 1, 2020

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Primary

Product

Line Code

Secondary

Product

Line Code

Description

21031 1/1/1990 D M EXCISION OF TORUS MANDIBULARIS

21440 1/1/1985 D M

CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY

ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE)

21445 1/1/1985 D M

OPEN TREATMENT OF MANDIBULAR OR MAXILLARY

ALVEOLAR RIDGE FRACTURE (SEPARATE PROCEDURE)

40806 1/1/1985 D M INCISION OF LABIAL FRENUM (FRENOTOMY)

40819 1/1/1985 D M

EXCISION OF FRENUM, LABIAL OR BUCCAL

(FRENUMECTOMY, FRENULECTOMY, FRENECTOMY)

40840 1/1/1985 D M VESTIBULOPLASTY; ANTERIOR

40842 1/1/1985 D M VESTIBULOPLASTY; POSTERIOR, UNILATERAL

40843 1/1/1985 D M VESTIBULOPLASTY; POSTERIOR, BILATERAL

40844 1/1/1985 D M VESTIBULOPLASTY; ENTIRE ARCH

40845 1/1/1985 D M

VESTIBULOPLASTY; COMPLEX (INCLUDING RIDGE

EXTENSION, MUSCLE REPOSITIONING)

41520 1/1/1985 D M

FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG,

WITH Z-PLASTY)

41820 1/1/1985 D M GINGIVECTOMY, EXCISION GINGIVA, EACH QUADRANT

41821 1/1/1985 D M OPERCULECTOMY, EXCISION PERICORONAL TISSUES

41822 1/1/1985 D M

EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR

STRUCTURES

41823 1/1/1985 D M

EXCISION OF OSSEOUS TUBEROSITIES,

DENTOALVEOLAR STRUCTURES

41830 1/1/1985 D M

ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS

OR SEQUESTRECTOMY

41870 1/1/1985 D M PERIODONTAL MUCOSAL GRAFTING

41872 1/1/1985 D M GINGIVOPLASTY, EACH QUADRANT (SPECIFY)

41874 1/1/1985 D M ALVEOLOPLASTY, EACH QUADRANT (SPECIFY)

D0120 1/1/1985 D M PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT

D0140 1/1/1996 D M LIMITED ORAL EVALUATION - PROBLEM FOCUSED

D0145 1/1/2007 D M

ORAL EVALUATION FOR A PATIENT UNDER THREE

YEARS OF AGE AND COUNSELING WITH PRIMARY

CAREGIVER

The below list of codes are primary dental (D) and should be submitted to United Concordia Dental

first. These codes may processes as medical secondary.

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D0150 1/1/1996 D M

COMPREHENSIVE ORAL EVALUATION - NEW OR

ESTABLISHED PATIENT

D0160 1/1/1996 D M

DETAILED AND EXTENSIVE ORAL EVALUATION -

PROBLEM FOCUSED, BY REPORT

D0170 1/1/2000 D M

RE-EVALUATION - LIMITED, PROBLEM FOCUSED

(ESTABLISHED PATIENT; NOT POST-OPERATIVE VISIT)

D0171 1/1/2015 D M RE-EVALUATION - POST-OPERATIVE OFFICE VISIT

D0180 1/1/2003 D M

COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR

ESTABLISHED PATIENT

D0190 1/1/2013 D M SCREENING OF A PATIENT

D0191 1/1/2013 D M ASSESSMENT OF A PATIENT

D0210 1/1/1985 D M

INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC

IMAGES

D0220 1/1/1985 D M INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE

D0230 1/1/1985 D M

INTRAORAL - PERIAPICAL EACH ADDITIONAL

RADIOGRAPHIC IMAGE

D0240 1/1/1985 D M INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE

D0250 1/1/1985 D M

EXTRA-ORAL - 2D PROJECTION RADIOGRAPHIC IMAGE

CREATED USING A STATIONARY RADIATION SOURCE,

AND DETECTOR

D0251 1/1/2016 D M EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE

D0270 1/1/1985 D M BITEWING - SINGLE RADIOGRAPHIC IMAGE.

D0272 1/1/1985 D M BITEWINGS - TWO RADIOGRAPHIC IMAGES.

D0273 1/1/2007 D M BITEWINGS - THREE RADIOGRAPHIC IMAGES

D0274 1/1/1985 D M BITEWINGS - FOUR RADIOGRAPHIC IMAGES.

D0277 1/1/2000 D M VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES

D0310 1/1/1986 D M SIALOGRAPHY

D0320 1/1/1986 D M

TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING

INJECTION

D0321 1/1/1985 D M

OTHER TEMPOROMANDIBULAR JOINT RADIOGRAPHIC

IMAGES, BY REPORT

D0322 1/1/1992 D M TOMOGRAPHIC SURVEY

D0330 1/1/1985 D M PANORAMIC RADIOGRAPHIC IMAGE

D0340 1/1/1985 D M

2D CEPHALOMETRIC RADIOGRAPHIC IMAGE -

ACQUISITION, MEASUREMENT AND ANALYSIS

D0350 1/1/2000 D M

2D ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED

INTRA-ORALLY OR EXTRA-ORALLY

D0351 1/1/2015 D M 3D PHOTOGRAPHIC IMAGE

D0364 1/1/2013 D M

CONE BEAM CT CAPTURE AND INTERPRETATION WITH

LIMITED FIELD OF VIEW - LESS THAN ONE WHOLE JAW

D0365 1/1/2013 D M


FIELD OF VIEW OF ONE FULL DENTAL ARCH - MANDIBLE

D0366 1/1/2013 D M


FIELD OF VIEW OF ONE FULL DENTAL ARCH - MAXILLA,

WITH OR WITHOUT CRANIUM

D0367 1/1/2013 D M


FIELD OF VIEW OF BOTH JAWS, WITH OR WITHOUT

CRANIUM

D0368 1/1/2013 D M

CONE BEAM CT CAPTURE AND INTERPRETATION FOR

TMJ SERIES INCLUDING TWO OR MORE EXPOSURES

D0369 1/1/2013 D M MAXILLOFACIAL MRI CAPTURE AND INTERPRETATION

D0370 1/1/2013 D M

MAXILLOFACIAL ULTRASOUND CAPTURE AND

INTERPRETATION

D0371 1/1/2013 D M SIALOENDOSCOPY CAPTURE AND INTERPRETATION

D0380 1/1/2013 D M

CONE BEAM CT IMAGE CAPTURE WITH LIMITED FIELD OF

VIEW - LESS THAN ONE WHOLE JAW

D0381 1/1/2013 D M

CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF

ONE FULL DENTAL ARCH - MANDIBLE

D0382 1/1/2013 D M


ONE FULL DENTAL ARCH - MAXILLA, WITH OR WITHOUT

CRANIUM

D0383 1/1/2013 D M


BOTH JAWS, WITH OR WITHOUT CRANIUM

D0384 1/1/2013 D M

CONE BEAM CT IMAGE CAPTURE FOR TMJ SERIES

INCLUDING TWO OR MORE EXPOSURES

D0385 1/1/2013 D M MAXILLOFACIAL MRI IMAGE CAPTURE

D0386 1/1/2013 D M MAXILLOFACIAL ULTRASOUND IMAGE CAPTURE

D0391 1/1/2013 D M

INTERPRETATION OF DIAGNOSTIC IMAGE BY A

PRACTITIONER NOT ASSOCIATED WITH CAPTURE OF

THE IMAGE, INCLUDING REPORT

D0393 1/1/2014 D M TREATMENT SIMULATION USING 3D IMAGE VOLUME

D0394 1/1/2014 D M

DIGITAL SUBTRACTION OF TWO OR MORE IMAGES OR

IMAGE VOLUMES OF THE SAME MODALITY

D0395 1/1/2014 D M

FUSION OF TWO OR MORE 3D IMAGE VOLUMES OF ONE

OR MORE MODALITIES

D0411 1/1/2018 D M HBA1C IN-OFFICE POINT OF SERVICE TESTING

D0414 1/1/2017 D M

LABORATORY PROCESSING OF MICROBIAL SPECIMEN TO

INCLUDE CULTURE AND SENSITIVITY STUDIES,

PREPARATION AND TRANSMISSION OF WRITTEN

REPORT

D0415 1/1/1992 D M

COLLECTION OF MICROORGANISMS FOR CULTURE AND

SENSITIVITY

D0416 1/1/2005 D M VIRAL CULTURE

D0417 1/1/2009 D M

COLLECTION AND PREPARATION OF SALIVA SAMPLE

FOR LABORATORY DIAGNOSTIC TESTING

D0418 1/1/2009 D M ANALYSIS OF SALIVA SAMPLE

D0425 1/1/1992 D M CARIES SUSCEPTIBILITY TESTS

D0431 1/1/2005 D M

ADJUNCTIVE PRE-DIAGNOSTIC TEST THAT AIDS IN

DETECTION OF MUCOSAL ABNORMALITIES INCLUDING

PREMALIGNANT AND MALIGNANT LESIONS, NOT TO

INCLUDE CYTOLOGY OR BIOPSY PROCEDURES

D0460 1/1/1985 D M PULP VITALITY TESTS

D0470 1/1/1985 D M DIAGNOSTIC CASTS

D0472 1/1/2000 D M

ACCESSION OF TISSUE, GROSS EXAMINATION,


REPORT

D0473 1/1/2000 D M

ACCESSION OF TISSUE, GROSS AND MICROSCOPIC

EXAMINATION, PREPARATION AND TRANSMISSION OF

WRITTEN REPORT

D0474 1/1/2000 D M

ACCESSION OF TISSUE, GROSS AND MICROSCOPIC

EXAMINATION, INCLUDING ASSESSMENT OF SURGICAL

MARGINS FOR PRESENCE OF DISEASE, PREPARATION

AND TRANSMISSION OF WRITTEN REPORT

D0475 1/1/2005 D M DECALCIFICATION PROCEDURE

D0476 1/1/2005 D M SPECIAL STAINS FOR MICROORGANISMS

D0477 1/1/2005 D M SPECIAL STAINS, NOT FOR MICROORGANISMS

D0478 1/1/2005 D M IMMUNOHISTOCHEMICAL STAINS

D0479 1/1/2005 D M

TISSUE IN-SITU HYBRIDIZATION, INCLUDING

INTERPRETATION

D0480 1/1/2000 D M

ACCESSION OF EXFOLIATIVE CYTOLOGIC SMEARS,

MICROSCOPIC EXAMINATION, PREPARATION AND

TRANSMISSION OF WRITTEN REPORT

D0481 1/1/2005 D M ELECTRON MICROSCOPY

D0482 1/1/2005 D M DIRECT IMMUNOFLUORESCENCE

D0483 1/1/2005 D M INDIRECT IMMUNOFLUORESCENCE

D0484 1/1/2005 D M CONSULTATION ON SLIDES PREPARED ELSEWHERE

D0485 1/1/2005 D M

CONSULTATION, INCLUDING PREPARATION OF SLIDES

FROM BIOPSY MATERIAL SUPPLIED BY REFERRING

SOURCE

D0486 1/1/2007 D M

LABORATORY ACCESSION OF TRANSEPITHELIAL

CYTOLOGIC SAMPLE, MICROSCOPIC EXAMINATION,


REPORT

D0502 1/1/1986 D M OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT

D0600 1/1/2017 D M

NON-IONIZING DIAGNOSTIC PROCEDURE CAPABLE OF

QUANTIFYING, MONITORING, AND RECORDING CHANGES

IN STRUCTURE OF ENAMEL, DENTIN AND CEMENTUM

D0601 1/1/2014 D M

CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH

A FINDING OF LOW RISK

D0602 1/1/2014 D M


A FINDING OF MODERATE RISK

D0603 1/1/2014 D M


A FINDING OF HIGH RISK

D0999 1/1/1985 D M UNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORT

D1110 1/1/1985 D M PROPHYLAXIS - ADULT

D1120 1/1/1985 D M PROPHYLAXIS - CHILD

D1206 1/1/2007 D M TOPICAL APPLICATION OF FLUORIDE VARNISH

D1208 1/1/2013 D M TOPICAL APPLICATION OF FLUORIDE

D1310 1/1/1985 D M

NUTRITIONAL COUNSELING FOR CONTROL OF DENTAL

DISEASE

D1320 1/1/1996 D M

TOBACCO COUNSELING FOR THE CONTROL AND

PREVENTION OF ORAL DISEASE

D1330 1/1/1985 D M ORAL HYGIENE INSTRUCTIONS

D1351 1/1/1985 D M SEALANT - PER TOOTH

D1352 1/1/2011 D M

PREVENTIVE RESIN RESTORATION IN A MODERATE TO

HIGH CARIES RISK PATIENT - PERMANENT TOOTH

D1353 1/1/2015 D M SEALANT REPAIR - PER TOOTH

D1354 1/1/2016 D M

INTERIM CARIES ARRESTING MEDICAMENT APPLICATION -

PER TOOTH

D1510 1/1/1985 D M

SPACE MAINTAINER - FIXED, UNILATERAL - PER

QUADRANT

D1520 1/1/1985 D M

SPACE MAINTAINER - REMOVABLE, UNILATERAL - PER

QUADRANT

D1551 1/1/2020 D M

RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER

- MAXILLARY

D1552 1/1/2020 D M

RE-CEMENT OR RE-BOND BILATERAL SPACE MAINTAINER

- MANDIBULAR

D1553 1/1/2020 D M

RE-CEMENT OR RE-BOND UNILATERAL SPACE

MAINTAINER - PER QUADRANT

D1556 1/1/2020 D M

REMOVAL OF FIXED UNILATERAL SPACE MAINTAINER -

PER QUADRANT

D1557 1/1/2020 D M

REMOVAL OF FIXED BILATERAL SPACE MAINTAINER -

MAXILLARY

D1558 1/1/2020 D M

REMOVAL OF FIXED BILATERAL SPACE MAINTAINER -

MANDIBULAR

D1575 1/1/2017 D M

DISTAL SHOE SPACE MAINTAINER - FIXED, UNILATERAL -

PER QUADRANT

D1999 1/1/2014 D M UNSPECIFIED PREVENTIVE PROCEDURE, BY REPORT

D2140 1/1/1985 D M AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT

D2150 1/1/1985 D M AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT

D2160 1/1/1985 D M

AMALGAM - THREE SURFACES, PRIMARY OR

PERMANENT

D2161 1/1/1985 D M

AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR

PERMANENT

D2330 1/1/1985 D M RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR

D2331 1/1/1985 D M RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR

D2332 1/1/1985 D M

RESIN-BASED COMPOSITE - THREE SURFACES,

ANTERIOR

D2335 1/1/1985 D M

RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES

OR INVOLVING INCISAL ANGLE (ANTERIOR)

D2390 1/1/2003 D M RESIN-BASED COMPOSITE CROWN, ANTERIOR

D2391 1/1/2003 D M RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR

D2392 1/1/2003 D M

RESIN-BASED COMPOSITE - TWO SURFACES,

POSTERIOR

D2393 1/1/2003 D M

RESIN-BASED COMPOSITE - THREE SURFACES,

POSTERIOR

D2394 1/1/2003 D M

RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES,

POSTERIOR

D2410 1/1/1985 D M GOLD FOIL - ONE SURFACE

D2420 1/1/1985 D M GOLD FOIL - TWO SURFACES

D2430 1/1/1985 D M GOLD FOIL - THREE SURFACES

D2510 1/1/1985 D M INLAY - METALLIC - ONE SURFACE

D2520 1/1/1985 D M INLAY - METALLIC - TWO SURFACES

D2530 1/1/1985 D M INLAY - METALLIC - THREE OR MORE SURFACES

D2542 1/1/2000 D M ONLAY - METALLIC - TWO SURFACES

D2543 1/1/1996 D M ONLAY - METALLIC - THREE SURFACES

D2544 1/1/1996 D M ONLAY - METALLIC - FOUR OR MORE SURFACES

D2610 1/1/1985 D M INLAY - PORCELAIN/CERAMIC - ONE SURFACE

D2620 1/1/1986 D M INLAY - PORCELAIN/CERAMIC - TWO SURFACES

D2630 1/1/1986 D M

INLAY - PORCELAIN/CERAMIC - THREE OR MORE

SURFACES

D2642 1/1/1996 D M ONLAY - PORCELAIN/CERAMIC - TWO SURFACES

D2643 1/1/1996 D M ONLAY - PORCELAIN/CERAMIC - THREE SURFACES

D2644 1/1/1996 D M

ONLAY - PORCELAIN/CERAMIC - FOUR OR MORE

SURFACES

D2650 1/1/1992 D M INLAY - RESIN-BASED COMPOSITE - ONE SURFACE

D2651 1/1/1992 D M INLAY - RESIN-BASED COMPOSITE - TWO SURFACES

D2652 1/1/1992 D M

INLAY - RESIN-BASED COMPOSITE - THREE OR MORE

SURFACES

D2662 1/1/1996 D M ONLAY - RESIN-BASED COMPOSITE - TWO SURFACES

D2663 1/1/1996 D M ONLAY - RESIN-BASED COMPOSITE - THREE SURFACES

D2664 1/1/1996 D M

ONLAY - RESIN-BASED COMPOSITE - FOUR OR MORE

SURFACES

D2710 1/1/1985 D M CROWN - RESIN-BASED COMPOSITE (INDIRECT)

D2712 1/1/2005 D M CROWN - 3/4 RESIN-BASED COMPOSITE (INDIRECT)

D2720 1/1/1985 D M CROWN - RESIN WITH HIGH NOBLE METAL

D2721 1/1/1985 D M CROWN - RESIN WITH PREDOMINANTLY BASE METAL

D2722 1/1/1985 D M CROWN - RESIN WITH NOBLE METAL

D2740 1/1/1985 D M CROWN - PORCELAIN/CERAMIC

D2750 1/1/1985 D M CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL

D2751 1/1/1986 D M

CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE

METAL

D2752 1/1/1985 D M CROWN - PORCELAIN FUSED TO NOBLE METAL

D2753 1/1/2020 D M

CROWN - PORCELAIN FUSED TO TITANIUM AND TITANIUM

ALLOYS

D2780 1/1/2000 D M CROWN - 3/4 CAST HIGH NOBLE METAL

D2781 1/1/2000 D M CROWN - 3/4 CAST PREDOMINANTLY BASE METAL

D2782 1/1/2000 D M CROWN - 3/4 CAST NOBLE METAL

D2783 1/1/2000 D M CROWN - 3/4 PORCELAIN/CERAMIC

D2790 1/1/1985 D M CROWN - FULL CAST HIGH NOBLE METAL

D2791 1/1/1985 D M CROWN - FULL CAST PREDOMINANTLY BASE METAL

D2792 1/1/1985 D M CROWN - FULL CAST NOBLE METAL

D2794 1/1/2005 D M CROWN - TITANIUM AND TITANIUM ALLOYS

D2799 1/1/2000 D M

PROVISIONAL CROWN - FURTHER TREATMENT OR

COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO

FINAL IMPRESSION

D2910 1/1/1985 D M

RECEMENT INLAY, ONLAY, OR PARTIAL COVERAGE

RESTORATION

D2915 1/1/2005 D M

RE-CEMENT OR RE-BOND INDIRECTLY FABRICATED OR

PREFABRICATED POST AND CORE

D2920 1/1/1985 D M RE-CEMENT OR RE-BOND CROWN

D2921 1/1/2014 D M

REATTACHMENT OF TOOTH FRAGMENT, INCISAL EDGE

OR CUSP

D2929 1/1/2013 D M

PREFABRICATED PORCELAIN/CERAMIC CROWN -

PRIMARY TOOTH

D2930 1/1/1986 D M

PREFABRICATED STAINLESS STEEL CROWN - PRIMARY

TOOTH

D2931 1/1/1986 D M

PREFABRICATED STAINLESS STEEL CROWN -

PERMANENT TOOTH

D2932 1/1/1986 D M PREFABRICATED RESIN CROWN

D2933 1/1/1992 D M

PREFABRICATED STAINLESS STEEL CROWN WITH RESIN

WINDOW

D2934 1/1/2005 D M

PREFABRICATED ESTHETIC COATED STAINLESS STEEL

CROWN - PRIMARY TOOTH

D2940 1/1/1985 D M PROTECTIVE RESTORATION

D2941 1/1/2014 D M

INTERIM THERAPEUTIC RESTORATION - PRIMARY

DENTITION

D2949 1/1/2014 D M

RESTORATIVE FOUNDATION FOR AN INDIRECT

RESTORATION

D2950 1/1/1986 D M CORE BUILDUP, INCLUDING ANY PINS WHEN REQUIRED

D2951 1/1/1986 D M

PIN RETENTION - PER TOOTH, IN ADDITION TO

RESTORATION

D2952 1/1/1986 D M

POST AND CORE IN ADDITION TO CROWN, INDIRECTLY

FABRICATED

D2953 1/1/2000 D M

EACH ADDITIONAL INDIRECTLY FABRICATED POST -

SAME TOOTH

D2954 1/1/1986 D M

PREFABRICATED POST AND CORE IN ADDITION TO

CROWN

D2955 1/1/1996 D M POST REMOVAL

D2957 1/1/2000 D M EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH

D2960 1/1/1985 D M LABIAL VENEER (RESIN LAMINATE) - CHAIRSIDE

D2961 1/1/1992 D M LABIAL VENEER (RESIN LAMINATE) - LABORATORY

D2962 1/1/1992 D M LABIAL VENEER (PORCELAIN LAMINATE) - LABORATORY

D2971 1/1/2005 D M

ADDITIONAL PROCEDURES TO CONSTRUCT NEW

CROWN UNDER EXISTING PARTIAL DENTURE

FRAMEWORK

D2975 1/1/2005 D M COPING

D2980 1/1/1986 D M

CROWN REPAIR NECESSITATED BY RESTORATIVE

MATERIAL FAILURE

D2981 1/1/2013 D M

INLAY REPAIR NECESSITATED BY RESTORATIVE

MATERIAL FAILURE

D2982 1/1/2013 D M

ONLAY REPAIR NECESSITATED BY RESTORATIVE

MATERIAL FAILURE

D2983 1/1/2013 D M

VENEER REPAIR NECESSITATED BY RESTORATIVE

MATERIAL FAILURE

D2990 1/1/2013 D M

RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE

LESIONS

D2999 1/1/1986 D M UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT

D3110 1/1/1985 D M PULP CAP - DIRECT (EXCLUDING FINAL RESTORATION)

D3120 1/1/1985 D M PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION)

D3220 1/1/1985 D M

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL

RESTORATION)- REMOVAL OF PULP CORONAL TO THE

DENTINOCEMENTAL JUNCTION AND APPLICATION OF

MEDICAMENT

D3221 1/1/2000 D M

PULPAL DEBRIDEMENT, PRIMARY AND PERMANENT

TEETH

D3222 1/1/2009 D M

PARTIAL PULPOTOMY FOR APEXOGENESIS -

PERMANENT TOOTH WITH INCOMPLETE ROOT

DEVELOPMENT

D3230 1/1/1996 D M

PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR,

PRIMARY TOOTH (EXCLUDING FINAL RESTORATION)

D3240 1/1/1996 D M

PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR,

PRIMARY TOOTH (EXCLUDING FINAL RESTORATION)

D3310 1/1/1985 D M

ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING

FINAL RESTORATION)

D3330 1/1/1985 D M

ENDODONTIC THERAPY, MOLAR TOOTH (EXCLUDING

FINAL RESTORATIONS)

D3331 1/1/2000 D M

TREATMENT OF ROOT CANAL OBSTRUCTION; NON-

SURGICAL ACCESS

D3332 1/1/2000 D M

INCOMPLETE ENDODONTIC THERAPY; INOPERABLE

UNRESTORABLE OR FRACTURED TOOTH

D3333 1/1/2000 D M INTERNAL ROOT REPAIR OF PERFORATION DEFECTS

D3346 1/1/1992 D M

RETREATMENT OF PREVIOUS ROOT CANAL THERAPY -

ANTERIOR

D3348 1/1/1992 D M

RETREATMENT OF PREVIOUS ROOT CANAL THERAPY -

MOLAR

D3351 1/1/1992 D M

APEXIFICATION/RECALCIFICATION - INITIAL VISIT (APICAL

CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT

RESORPTION, ETC.)

D3352 1/1/1992 D M

APEXIFICATION/RECALCIFICATION - INTERIM MEDICATION

REPLACEMENT (APICAL CLOSURE/CALCIFIC REPAIR OF

PERFORATIONS, ROOT RESORPTION, PULPAL SPACE

DISINFECTION, ETC.)

D3353 1/1/1992 D M

APEXIFICATION/RECALCIFICATION-FINAL VISIT

(INCLUDES COMPLETED ROOT CANAL THERAPY-APICAL

CLOSURE/CALCIFIC REPAIR OF PERFORATIONS, ROOT

RESORPTION, ETC.)

D3355 1/1/2014 D M PULPAL REGENERATION - INITIAL VISIT

D3356 1/1/2014 D M

PULPAL REGENERATION - INTERIM MEDICATION

REPLACEMENT

D3357 1/1/2014 D M PULPAL REGENERATION - COMPLETION OF TREATMENT

D3410 1/1/1985 D M APICOECTOMY - ANTERIOR

D3425 1/1/1992 D M APICOECTOMY - MOLAR (FIRST ROOT)

D3426 1/1/1992 D M APICOECTOMY (EACH ADDITIONAL ROOT)

D3427 1/1/2014 D M PERIRADICULAR SURGERY WITHOUT APICOECTOMY

D3428 1/1/2014 D M

BONE GRAFT IN CONJUNCTION WITH PERIRADICULAR

SURGERY - PER TOOTH, SINGLE SITE

D3429 1/1/2014 D M

BONE GRAFT IN CONJUNCTION WITH PERIRADICULAR

SURGERY - EACH ADDITIONAL CONTIGUOUS TOOTH IN

THE SAME SURGICAL SITE

D3430 1/1/1985 D M RETROGRADE FILLING - PER ROOT

D3431 1/1/2014 D M

BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS

TISSUE REGENERATION IN CONJUNCTION WITH

PERIRADICULAR SURGERY

D3432 1/1/2014 D M

GUIDED TISSUE REGENERATION, RESORBABLE

BARRIER, PER SITE, IN CONJUNCTION WITH

PERIRADICULAR SURGERY

D3450 1/1/1985 D M ROOT AMPUTATION - PER ROOT

D3460 1/1/1985 D M ENDODONTIC/ENDOSSEOUS IMPLANTS

D3470 1/1/1992 D M

INTENTIONAL REIMPLANTATION (INCLUDING NECESSARY

SPLINTING)

D3910 1/1/1985 D M

SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH

RUBBER DAM

D3920 1/1/1985 D M

HEMISECTION (INCLUDING ANY ROOT REMOVAL) NOT

INCLUDING ROOT CANAL THERAPY

D3950 1/1/1985 D M

CANAL PREPARATION AND FITTING OF PREFORMED

DOWEL OR POST

D3999 1/1/1985 D M UNSPECIFIED ENDODONTIC PROCEDURE (BY REPORT)

D4210 1/1/1985 D M

GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE

CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER

QUADRANT

D4211 1/1/1986 D M

GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE


QUADRANT

D4212 1/1/2013 D M

GINGIVECTOMY OR GINGIVOPLASTY TO ALLOW ACCESS

FOR RESTORATIVE PROCEDURE, PER TOOTH

D4230 1/1/2007 D M

ANATOMICAL CROWN EXPOSURE - FOUR OR MORE


QUADRANT

D4231 1/1/2007 D M

ANATOMICAL CROWN EXPOSURE - ONE TO THREE

TEETH OR TOOTH BOUNDED SPACES PER QUADRANT

D4240 1/1/1985 D M

GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING -

FOUR OR MORE CONTIGUOUS TEETH OR TOOTH

BOUNDED SPACES PER QUADRANT

D4241 1/1/2003 D M

GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING -

ONE TO THREE CONTIGUOUS TEETH OR TOOTH

BOUNDED SPACES PER QUADRANT

D4245 1/1/2000 D M APICALLY POSITIONED FLAP

D4249 1/1/1992 D M CLINICAL CROWN LENGTHENING-HARD TISSUE

D4260 1/1/1985 D M

OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL

THICKNESS FLAP AND CLOSURE) - FOUR OR MORE


QUADRANT

D4261 1/1/2003 D M

OSSEOUS SURGERY (INCLUDING ELEVATION OF A FULL

THICKNESS FLAP AND CLOSURE) - ONE TO THREE


QUADRANT

D4263 1/1/1996 D M

BONE REPLACEMENT GRAFT - RETAINED NATURAL

TOOTH - FIRST SITE IN QUADRANT

D4264 1/1/1996 D M

BONE REPLACEMENT GRAFT - RETAINED NATURAL

TOOTH - EACH ADDITIONAL SITE IN QUADRANT

D4265 1/1/2003 D M

BIOLOGIC MATERIALS TO AID IN SOFT AND OSSEOUS

TISSUE REGENERATION

D4266 1/1/1996 D M

GUIDED TISSUE REGENERATION - RESORBABLE

BARRIER, PER SITE

D4267 1/1/1996 D M

GUIDED TISSUE REGENERATION - NONRESORBABLE

BARRIER, PER SITE, (INCLUDES MEMBRANE REMOVAL)

D4268 1/1/2000 D M SURGICAL REVISION PROCEDURE, PER TOOTH

D4270 1/1/1985 D M PEDICLE SOFT TISSUE GRAFT PROCEDURE

D4273 1/1/1996 D M

AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE

(INCLUDING DONOR AND RECIPIENT SURGICAL SITES)

FIRST TOOTH, IMPLANT, OR EDENTULOUS TOOTH

POSITION IN GRAFT

D4274 1/1/1996 D M

MESIAL/DISTAL WEDGE PROCEDURE, SINGLE TOOTH

(WHEN NOT PERFORMED IN CONJUNCTION WITH

SURGICAL PROCEDURES IN THE SAME ANATOMICAL

AREA)

D4275 1/1/2003 D M

NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT

(INCLUDING RECIPIENT SITE AND DONOR MATERIAL)

FIRST TOOTH, IMPLANT, OR EDENTULOUS TOOTH

POSITION IN GRAFT

D4276 1/1/2003 D M

COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE

GRAFT, PER TOOTH

D4277 1/1/2013 D M

FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING

RECIPIENT AND DONOR SURGICAL SITES) FIRST TOOTH,

IMPLANT, OR EDENTULOUS TOOTH POSITION IN GRAFT

D4278 1/1/2013 D M

FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING

RECIPIENT AND DONOR SURGICAL SITES) EACH

ADDITIONAL CONTIGUOUS TOOTH, IMPLANT, OR

EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE

D4283 1/1/2016 D M

AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE

(INCLUDING DONOR AND RECIPIENT SURGICAL SITES) -

EACH ADDITIONAL CONTIGUOUS TOOTH, IMPLANT OR

EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE

D4285 1/1/2016 D M

NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT

PROCEDURE (INCLUDING RECIPIENT SURGICAL SITE AND

DONOR MATERIAL) - EACH ADDITIONAL CONTIGUOUS

TOOTH, IMPLANT, OR EDENTULOUS TOOTH POSITION IN

SAME GRAFT SITE

D4320 1/1/1985 D M PROVISIONAL SPLINTING - INTRACORONAL

D4321 1/1/1985 D M PROVISIONAL SPLINTING - EXTRACORONAL

D4341 1/1/1985 D M

PERIODONTAL SCALING AND ROOT PLANING - FOUR OR

MORE TEETH PER QUADRANT

D4342 1/1/2003 D M

PERIODONTAL SCALING AND ROOT PLANING - ONE TO

THREE TEETH PER QUADRANT

D4346 1/1/2017 D M

SCALING IN PRESENCE OF GENERALIZED MODERATE OR

SEVERE GINGIVAL INFLAMMATION FULL MOUTH, AFTER

ORAL EVALUATION

D4355 1/1/1996 D M

FULL MOUTH DEBRIDEMENT TO ENABLE A

COMPREHENSIVE ORAL EVALUATION AND DIAGNOSIS

ON A SUBSEQUENT VISIT

D4381 1/1/1996 D M

LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA

CONTROLLED RELEASE VEHICLE INTO DISEASED

CREVICULAR TISSUE, PER TOOTH

D4910 1/1/1985 D M PERIODONTAL MAINTENANCE

D4920 1/1/1985 D M

UNSCHEDULED DRESSING CHANGE (BY SOMEONE

OTHER THAN TREATING DENTIST OR THEIR STAFF)

D4921 1/1/2014 D M GINGIVAL IRRIGATION - PER QUADRANT

D4999 1/1/1985 D M UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORT

D5110 1/1/1985 D M COMPLETE DENTURE - MAXILLARY

D5120 1/1/1985 D M COMPLETE DENTURE - MANDIBULAR

D5130 1/1/1985 D M IMMEDIATE DENTURE - MAXILLARY

D5140 1/1/1985 D M IMMEDIATE DENTURE - MANDIBULAR

D5211 1/1/1985 D M

MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING

ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

D5212 1/1/1985 D M

MANDIBULAR PARTIAL DENTURE - RESIN BASE

(INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND

TEETH)

D5213 1/1/1985 D M

MAXILLARY PARTIAL DENTURE - CAST METAL

FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING

RETENTIVE/CLASPING MATERIALS, RESTS AND TEETH)

D5214 1/1/1985 D M

MANDIBULAR PARTIAL DENTURE - CAST METAL



D5221 1/1/2016 D M

IMMEDIATE MAXILLARY PARTIAL DENTURE - RESIN BASE

(INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS

AND TEETH)

D5222 1/1/2016 D M

IMMEDIATE MANDIBULAR PARTIAL DENTURE - RESIN

BASE (INCLUDING RETENTIVE/CLASPING MATERIALS,

RESTS AND TEETH)

D5223 1/1/2016 D M

IMMEDIATE MAXILLARY PARTIAL DENTURE - CAST METAL



D5224 1/1/2016 D M

IMMEDIATE MANDIBULAR PARTIAL DENTURE - CAST

METAL FRAMEWORK WITH RESIN DENTURE BASES

(INCLUDING RETENTIVE/CLASPING MATERIALS, RESTS

AND TEETH)

D5225 1/1/2005 D M

MAXILLARY PARTIAL DENTURE - FLEXIBLE BASE

(INCLUDING ANY CLASPS, RESTS AND TEETH)

D5226 1/1/2005 D M

MANDIBULAR PARTIAL DENTURE - FLEXIBLE BASE

(INCLUDING ANY CLASPS, RESTS AND TEETH)

D5280 1/1/1987 D M

REMOVABLE LOWER UNILATERAL PARTIAL - ONE

DENTURE, ONE PIECE CAST METAL - PER

D5282 1/1/1987 D M

REMOVEABLE UNILATERAL PARTIAL DENTURE - ONE

PIECE CAST METAL (INCLUDING CLASPS AND TEETH),

MAXILLARY

D5283 1/1/2019 D M

REMOVEABLE UNILATERAL PARTIAL DENTURE - ONE

PIECE CAST METAL (INCLUDING CLASPS AND TEETH),

MANDIBULAR

D5284 1/1/2020 D M

REMOVABLE UNILATERAL PARTIAL DENTURE - ONE

PIECE FLEXIBLE BASE (INCLUDING CLASPS AND TEETH) -

PER QUADRANT

D5286 1/1/2020 D M

REMOVABLE UNILATERAL PARTIAL DENTURE - ONE

PIECE RESIN (INCLUDING CLASPS AND TEETH) - PER

QUADRANT

D5410 1/1/1985 D M ADJUST COMPLETE DENTURE - MAXILLARY

D5411 1/1/1986 D M ADJUST COMPLETE DENTURE - MANDIBULAR

D5421 1/1/1985 D M ADJUST PARTIAL DENTURE - MAXILLARY

D5422 1/1/1985 D M ADJUST PARTIAL DENTURE - MANDIBULAR

D5511 1/1/2018 D M

REPAIR BROKEN COMPLETE DENTURE BASE,

MANDIBULAR

D5512 1/1/2018 D M REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY

D5520 1/1/1986 D M

REPLACE MISSING OR BROKEN TEETH - COMPLETE

DENTURE (EACH TOOTH)

D5611 1/1/2018 D M REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR

D5612 1/1/2018 D M REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY

D5621 1/1/2018 D M REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR

D5622 1/1/2018 D M REPAIR CAST PARTIAL FRAMEWORK, MANDIBULAR

D5630 1/1/1985 D M

REPAIR OR REPLACE BROKEN RETENTIVE CLASPING

MATERIALS - PER TOOTH

D5640 1/1/1985 D M REPLACE BROKEN TEETH - PER TOOTH

D5650 1/1/1985 D M ADD TOOTH TO EXISTING PARTIAL DENTURE

D5660 1/1/1985 D M

ADD CLASP TO EXISTING PARTIAL DENTURE - PER

TOOTH

D5670 1/1/2003 D M

REPLACE ALL TEETH AND ACRYLIC ON CAST METAL

FRAMEWORK (MAXILLARY)

D5671 1/1/2003 D M

REPLACE ALL TEETH AND ACRYLIC ON CAST METAL

FRAMEWORK (MANDIBULAR)

D5710 1/1/1985 D M REBASE COMPLETE MAXILLARY DENTURE

D5711 1/1/1986 D M REBASE COMPLETE MANDIBULAR DENTURE

D5720 1/1/1985 D M REBASE MAXILLARY PARTIAL DENTURE

D5721 1/1/1986 D M REBASE MANDIBULAR PARTIAL DENTURE

D5730 1/1/1985 D M RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)

D5731 1/1/1986 D M RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)

D5740 1/1/1985 D M RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)

D5741 1/1/1986 D M RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)

D5750 1/1/1985 D M RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)

D5751 1/1/1986 D M

RELINE COMPLETE MANDIBULAR DENTURE

(LABORATORY)

D5760 1/1/1985 D M RELINE MAXILLARY PARTIAL DENTURE (LABORATORY)

D5761 1/1/1986 D M RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY)

D5810 1/1/1985 D M INTERIM COMPLETE DENTURE (MAXILLARY)

D5811 1/1/1985 D M INTERIM COMPLETE DENTURE (MANDIBULAR)

D5820 1/1/1985 D M INTERIM PARTIAL DENTURE (MAXILLARY)

D5821 1/1/1985 D M INTERIM PARTIAL DENTURE (MANDIBULAR)

D5850 1/1/1985 D M TISSUE CONDITIONING, MAXILLARY

D5851 1/1/1992 D M TISSUE CONDITIONING, MANDIBULAR

D5862 1/1/1986 D M PRECISION ATTACHMENT, BY REPORT

D5863 1/1/2014 D M OVERDENTURE - COMPLETE MAXILLARY

D5864 1/1/2014 D M OVERDENTURE - PARTIAL MAXILLARY

D5865 1/1/2014 D M OVERDENTURE - COMPLETE MANDIBULAR

D5866 1/1/2014 D M OVERDENTURE - PARTIAL MANDIBULAR

D5867 1/1/2000 D M

REPLACEMENT OF REPLACEABLE PART OF SEMI-

PRECISION OR PRECISION ATTACHMENT (MALE OR

FEMALE COMPONENT)

D5875 1/1/2000 D M

MODIFICATION OF REMOVABLE PROSTHESIS

FOLLOWING IMPLANT SURGERY

D5876 1/1/2019 D M

ADD METAL SUBSTRUCTURE TO ACYRLIC FULL DENTURE

(PER ARCH)

D5899 1/1/1986 D M

UNSPECIFIED REMOVABLE PROSTHODONTIC

PROCEDURE, BY REPORT

D5911 1/1/1985 D M FACIAL MOULAGE (SECTIONAL)

D5912 1/1/1985 D M FACIAL MOULAGE (COMPLETE)

D5913 1/1/1985 D M NASAL PROSTHESIS

D5914 1/1/1985 D M AURICULAR PROSTHESIS

D5915 1/1/1985 D M ORBITAL PROSTHESIS

D5916 1/1/1985 D M OCULAR PROSTHESIS

D5919 1/1/1985 D M FACIAL PROSTHESIS

D5922 1/1/1992 D M NASAL SEPTAL PROSTHESIS

D5923 1/1/1992 D M OCULAR PROSTHESIS, INTERIM

D5924 1/1/1992 D M CRANIAL PROSTHESIS

D5925 1/1/1992 D M FACIAL AUGMENTATION IMPLANT PROSTHESIS

D5926 1/1/1992 D M NASAL PROSTHESIS, REPLACEMENT

D5927 1/1/1992 D M AURICULAR PROSTHESIS, REPLACEMENT

D5928 1/1/1992 D M ORBITAL PROSTHESIS, REPLACEMENT

D5929 1/1/1992 D M FACIAL PROSTHESIS, REPLACEMENT

D5931 1/1/1985 D M OBTURATOR PROSTHESIS, SURGICAL

D5932 1/1/1985 D M OBTURATOR PROSTHESIS, DEFINITIVE

D5933 1/1/1985 D M OBTURATOR PROSTHESIS, MODIFICATION

D5934 1/1/1985 D M

MANDIBULAR RESECTION PROSTHESIS WITH GUIDE

FLANGE

D5935 1/1/1985 D M

MANDIBULAR RESECTION PROSTHESIS WITHOUT GUIDE

FLANGE

D5936 1/1/1992 D M OBTURATOR PROSTHESIS, INTERIM

D5937 1/1/1992 D M TRISMUS APPLIANCE (NOT FOR TMD TREATMENT)

D5951 1/1/1985 D M FEEDING AID

D5952 1/1/1985 D M SPEECH AID PROSTHESIS, PEDIATRIC

D5953 1/1/1985 D M SPEECH AID PROSTHESIS, ADULT

D5954 1/1/1985 D M PALATAL AUGMENTATION PROSTHESIS

D5955 1/1/1985 D M PALATAL LIFT PROSTHESIS, DEFINITIVE

D5958 1/1/1992 D M PALATAL LIFT PROSTHESIS, INTERIM

D5959 1/1/1992 D M PALATAL LIFT PROSTHESIS, MODIFICATION

D5960 1/1/1992 D M SPEECH AID PROSTHESIS, MODIFICATION

D5982 1/1/1985 D M SURGICAL STENT

D5983 1/1/1985 D M RADIATION CARRIER

D5984 1/1/1985 D M RADIATION SHIELD

D5985 1/1/1985 D M RADIATION CONE LOCATOR

D5986 1/1/1985 D M FLUORIDE GEL CARRIER

D5987 1/1/1992 D M COMMISSURE SPLINT

D5988 1/1/1992 D M SURGICAL SPLINT

D5991 1/1/2009 D M VESICULOBULLOUS DISEASE MEDICAMENT CARRIER

D5992 1/1/2011 D M

ADJUST MAXILLOFACIAL PROSTHETIC APPLIANCE, BY

REPORT

D5993 1/1/2011 D M

MAINTENANCE AND CLEANING OF A MAXILLOFACIAL

PROSTHESIS (EXTRA OR INTRAORAL) OTHER THAN

REQUIRED ADJUSTMENTS, BY REPORT

D5994 1/1/2014 D M

PERIODONTAL MEDICAMENT CARRIER WITH PERIPHERAL

SEAL - LABORATORY PROCESSED

D5999 1/1/1986 D M UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT

D6010 1/1/1996 D M

SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL

IMPLANT

D6011 1/1/2014 D M SECOND STAGE IMPLANT SURGERY

D6012 1/1/2007 D M

SURGICAL PLACEMENT OF INTERIM IMPLANT BODY FOR

TRANSITIONAL PROSTHESIS: ENDOSTEAL IMPLANT

D6013 1/1/2014 D M SURGICAL PLACEMENT OF MINI IMPLANT

D6040 1/1/1992 D M SURGICAL PLACEMENT: EPOSTEAL IMPLANT

D6050 1/1/1992 D M SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT

D6051 1/1/2013 D M INTERIM ABUTMENT

D6052 1/1/2014 D M SEMI-PRECISION ATTACHMENT ABUTMENT

D6055 1/1/1992 D M

CONNECTING BAR - IMPLANT SUPPORTED OR ABUTMENT

SUPPORTED

D6056 1/1/2000 D M

PREFABRICATED ABUTMENT - INCLUDES MODIFICATION

AND PLACEMENT

D6057 1/1/2000 D M

CUSTOM FABRICATED ABUTMENT - INCLUDES

PLACEMENT

D6058 1/1/2000 D M ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN

D6059 1/1/2000 D M ABUTMENT SUPPORTED PROCELAIN/CERAMIC CROWN

D6060 1/1/2000 D M

ABUTMENT SUPPORTED PROCELAIN FUSED TO METAL

CROWN (PREDOMINANTLY BASE METAL)

D6061 1/1/2000 D M

ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL

CROWN (NOBLE METAL)

D6062 1/1/2000 D M

ABUTMENT SUPPORTED CAST METAL CROWN (HIGH

NOBLE METAL)

D6063 1/1/2000 D M

ABUTMENT SUPPORTED CAST METAL CROWN

(PREDOMINANTLY BASE METAL)

D6064 1/1/2000 D M

ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE

METAL)

D6065 1/1/2000 D M IMPLANT SUPPORTED PROCELAIN/CERAMIC CROWN

D6066 1/1/2000 D M

IMPLANT SUPPORTED CROWN - PORCELAIN FUSED TO

HIGH NOBLE ALLOYS

D6067 1/1/2000 D M IMPLANT SUPPORTED CROWN - HIGH NOBLE ALLOYS

D6068 1/1/2000 D M

ABUTMENT SUPPORTED RETAINER FOR

PROCELAIN/CERAMIC FPD

D6069 1/1/2000 D M

ABUTMENT SUPPORTED RETAINER FOR PORCELAIN

FUSED TO METAL FPD (HIGH NOBLE METAL)

D6070 1/1/2000 D M


FUSED TO METAL FPD (PREDOMINANTLY BASE METAL)

D6071 1/1/2000 D M


FUSED TO METAL FPD (NOBLE METAL)

D6072 1/1/2000 D M

ABUTMENT SUPPORTED RETAINER FOR CAST METAL

FPD (HIGH NOBLE METAL)

D6073 1/1/2000 D M


FPD (PREDOMINANTLY BASE METAL)

D6074 1/1/2000 D M


FPD (NOBLE METAL)

D6075 1/1/2000 D M IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD

D6076 1/1/2000 D M

IMPLANT SUPPORTED RETAINER FOR FPD - PORCELAIN

FUSED TO HIGH NOBLE ALLOYS

D6077 1/1/2000 D M

IMPLANT SUPPORTED RETAINER FOR METAL FPD - HIGH

NOBLE ALLOYS

D6080 1/1/1992 D M

IMPLANT MAINTENANCE PROCEDURES WHEN

PROSTHESES ARE REMOVED AND REINSERTED,

INCLUDING CLEANSING OF PROSTHESES AND

ABUTMENTS

D6081 1/1/2017 D M

SCALING AND DEBRIDEMENT IN THE PRESENCE OF

INFLAMMATION OR MUCOSITIS OF A SINGLE IMPLANT,

INCLUDING CLEANING OF THE IMPLANT SURFACES,

WITHOUT FLAP ENTRY AND CLOSURE

D6082 1/1/2020 D M


PREDOMINANTLY BASE ALLOYS

D6083 1/1/2020 D M


NOBLE ALLOYS

D6084 1/1/2020 D M


TITANIUM AND TITANIUM ALLOYS

D6085 1/1/2017 D M PROVISIONAL IMPLANT CROWN

D6086 1/1/2020 D M

IMPLANT SUPPORTED CROWN - PREDOMINANTLY BASE

ALLOYS

D6087 1/1/2020 D M IMPLANT SUPPORTED CROWN - NOBLE ALLOYS

D6088 1/1/2020 D M

IMPLANT SUPPORTED CROWN - TITANIUM AND TITANIUM

ALLOYS

D6090 1/1/1992 D M REPAIR IMPLANT SUPPORTED PROSTHESIS, BY REPORT

D6091 1/1/2007 D M

REPLACEMENT OF SEMI-PRECISION OR PRECISION

ATTACHMENT (MALE OR FEMALE COMPONENT) OF

IMPLANT/ABUTMENT SUPPORTED PROSTHESIS, PER

ATTACHMENT

D6092 1/1/2007 D M

RE-CEMENT OR RE-BOND IMPLANT/ABUTMENT

SUPPORTED CROWN

D6093 1/1/2007 D M

RE-CEMENT OR RE-BOND IMPLANT/ABUTMENT

SUPPORTED FIXED PARTIAL DENTURE

D6094 1/1/2005 D M

ABUTMENT SUPPORTED CROWN - TITANIUM AND

TITANIUM ALLOYS

D6095 1/1/1996 D M REPAIR IMPLANT ABUTMENT, BY REPORT

D6096 1/1/2018 D M REMOVE BROKEN IMPLANT RETAINING SCREW

D6097 1/1/2020 D M

ABUTMENT SUPPORTED CROWN - PORCELAIN FUSED TO


D6098 1/1/2020 D M

IMPLANT SUPPORTED RETAINER - PORCELAIN FUSED TO


D6099 1/1/2020 D M

IMPLANT SUPPORTED RETAINER FOR FPD - PORCELAIN

FUSED TO NOBLE ALLOYS

D6100 1/1/1992 D M IMPLANT REMOVAL, BY REPORT

D6101 1/1/2013 D M

DEBRIDEMENT OF A PERIIMPLANT DEFECT OR DEFECTS

SURROUNDING A SINGLE IMPLANT, AND SURFACE

CLEANING OF THE EXPOSED IMPLANT SURFACES,

INCLUDING FLAP ENTRY AND CLOSURE

D6102 1/1/2013 D M

DEBRIDEMENT AND OSSEOUS CONTOURING OF A

PERIIMPLANT DEFECT OR DEFECTS SURROUNDING A

SINGLE IMPLANT, AND INCLUDES SURFACE CLEANING

OF THE EXPOSED IMPLANT SURFACES, INCLUDING FLAP

ENTRY AND CLOSURE

D6103 1/1/2013 D M

BONE GRAFT FOR REPAIR OF PERI-IMPLANT DEFECT -

DOES NOT INCLUDE FLAP ENTRY AND CLOSURE

D6104 1/1/2013 D M BONE GRAFT AT TIME OF IMPLANT PLACEMENT

D6110 1/1/2015 D M

IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE

FOR EDENTULOUS ARCH - MAXILLARY

D6111 1/1/2015 D M


FOR EDENTULOUS ARCH - MANDIBULAR

D6112 1/1/2015 D M


FOR PARTIALLY EDENTULOUS ARCH - MAXILLARY

D6113 1/1/2015 D M


FOR PARTIALLY EDENTULOUS ARCH - MANDIBULAR

D6114 1/1/2015 D M

IMPLANT/ABUTMENT SUPPORTED FIXED DENTURE FOR

EDENTULOUS ARCH - MAXILLARY

D6115 1/1/2015 D M


EDENTULOUS ARCH - MANDIBULAR

D6116 1/1/2015 D M


PARTIALLY EDENTULOUS ARCH - MAXILLARY

D6117 1/1/2015 D M


PARTIALLY EDENTULOUS ARCH - MANDIBULAR

D6118 1/1/2018 D M

IMPLANT/ABUTMENT SUPPORTED INTERIM FIXED

DENTURE FOR EDENTULOUS ARCH - MANDIBULAR

D6119 1/1/2018 D M

IMPLANT/ABUTMENT SUPPORTED INTERIM FIXED

DENTURE FOR EDENTULOUS ARCH - MAXILLARY

D6120 1/1/2020 D M

IMPLANT SUPPORTED RETAINER - PORCELAIN FUSED TO


D6121 1/1/2020 D M

IMPLANT SUPPORTED RETAINER FOR METAL FPD -


D6122 1/1/2020 D M


NOBLE ALLOYS

D6123 1/1/2020 D M



D6190 1/1/2005 D M RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT

D6194 1/1/2005 D M

ABUTMENT SUPPORTED RETAINER CROWN FOR FPD -


D6195 1/1/2020 D M

ABUTMENT SUPPORTED RETAINER - PORCELAIN FUSED

TO TITANIUM AND TITANIUM ALLOYS

D6199 1/1/1992 D M UNSPECIFIED IMPLANT PROCEDURE, BY REPORT

D6205 1/1/2005 D M PONTIC - INDIRECT RESIN BASED COMPOSITE

D6210 1/1/1985 D M PONTIC - CAST HIGH NOBLE METAL

D6211 1/1/1985 D M PONTIC - CAST PREDOMINATLY BASE METAL

D6212 1/1/1985 D M PONTIC - CAST NOBLE METAL

D6214 1/1/2005 D M PONTIC - TITANIUM AND TITANIUM ALLOYS

D6240 1/1/1985 D M PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL

D6241 1/1/1985 D M

PONTIC - PORCELAIN FUSED TO PREDOMINANTLY BASE

METAL

D6242 1/1/1985 D M PONTIC - PORCELAIN FUSED TO NOBLE METAL

D6243 1/1/2020 D M

PONTIC - PORCELAIN FUSED TO TITANIUM AND TITANIUM

ALLOYS

D6245 1/1/2000 D M PONTIC - PROCELAIN/CERAMIC

D6250 1/1/1985 D M PONTIC - RESIN WITH HIGH NOBLE METAL

D6251 1/1/1985 D M PONTIC - RESIN WITH PREDOMINANTLY BASE METAL

D6252 1/1/1985 D M PONTIC - RESIN WITH NOBLE METAL

D6253 1/1/2003 D M

PROVISIONAL PONTIC- FURTHER TREATMENT OR

COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO

FINAL IMPRESSION

D6545 1/1/1985 D M

RETAINER - CAST METAL FOR RESIN BONDED FIXED

PROSTHESIS

D6548 1/1/2000 D M

RETAINER - PORCELAIN/CERAMIC FOR RESIN BONDED

FIXED PROSTHESIS

D6549 1/1/2015 D M

RESIN RETAINER - FOR RESIN BONDED FIXED

PROSTHESIS

D6600 1/1/2003 D M

RETAINER INLAY - PORCELAIN/CERAMIC, TWO

SURFACES

D6601 1/1/2003 D M

RETAINER INLAY - PORCELAIN/CERAMIC, THREE OR

MORE SURFACES

D6602 1/1/2003 D M

RETAINER INLAY - CAST HIGH NOBLE METAL, TWO

SURFACES

D6603 1/1/2003 D M

RETAINER INLAY - CAST HIGH NOBLE METAL, THREE OR

MORE SURFACES

D6604 1/1/2003 D M

RETAINER INLAY - CAST PREDOMINANTLY BASE METAL,

TWO SURFACES

D6605 1/1/2003 D M

RETAINER INLAY - CAST PREDOMINANTLY BASE METAL,

THREE OR MORE SURFACES

D6606 1/1/2003 D M RETAINER INLAY - CAST NOBLE METAL, TWO SURFACES

D6607 1/1/2003 D M

RETAINER INLAY - CAST NOBLE METAL, THREE OR MORE

SURFACES

D6608 1/1/2003 D M

RETAINER ONLAY - PORCELAIN/CERAMIC, TWO

SURFACES

D6609 1/1/2003 D M

RETAINER ONLAY - PORCELAIN/CERAMIC, THREE OR

MORE SURFACES

D6610 1/1/2003 D M

RETAINER ONLAY - CAST HIGH NOBLE METAL, TWO

SURFACES

D6611 1/1/2003 D M

RETAINER ONLAY - CAST HIGH NOBLE METAL, THREE OR

MORE SURFACES

D6612 1/1/2003 D M

RETAINER ONLAY - CAST PREDOMINANTLY BASE METAL,

TWO SURFACES

D6613 1/1/2003 D M

RETAINER ONLAY - CAST PREDOMINANTLY BASE METAL,

THREE OR MORE SURFACES

D6614 1/1/2003 D M RETAINER ONLAY - CAST NOBLE METAL, TWO SURFACES

D6615 1/1/2003 D M

RETAINER ONLAY - CAST NOBLE METAL, THREE OR

MORE SURFACES

D6624 1/1/2005 D M RETAINER INLAY - TITANIUM

D6634 1/1/2005 D M RETAINER ONLAY - TITANIUM

D6710 1/1/2005 D M RETAINER CROWN - INDIRECT RESIN BASED COMPOSITE

D6720 1/1/1985 D M RETAINER CROWN - RESIN WITH HIGH NOBLE METAL

D6721 1/1/1986 D M

RETAINER CROWN - RESIN WITH PREDOMINANTLY BASE

METAL

D6722 1/1/1985 D M RETAINER CROWN - RESIN WITH NOBLE METAL

D6740 1/1/2000 D M RETAINER CROWN - PORCELAIN/CERAMIC

D6750 1/1/1985 D M

RETAINER CROWN - PORCELAIN FUSED TO HIGH NOBLE

METAL

D6751 1/1/1985 D M

RETAINER CROWN - PORCELAIN FUSED TO

PREDOMINANTLY BASE METAL

D6752 1/1/1985 D M

RETAINER CROWN - PORCELAIN FUSED TO NOBLE

METAL

D6753 1/1/2020 D M

RETAINER CROWN - PORCELAIN FUSED TO TITANIUM

AND TITANIUM ALLOYS

D6780 1/1/1985 D M RETAINER CROWN -3/4 CAST HIGH NOBLE METAL

D6781 1/1/2000 D M

RETAINER CROWN - 3/4 CAST PREDOMINANTLY BASE

METAL

D6782 1/1/2000 D M RETAINER CROWN - 3/4 CAST NOBLE METAL

D6783 1/1/2000 D M RETAINER CROWN - 3/4 PORCELAIN/CERAMIC

D6784 1/1/2020 D M RETAINER CROWN 3/4 - TITANIUM AND TITANIUM ALLOYS

D6790 1/1/1985 D M RETAINER CROWN - FULL CAST HIGH NOBLE METAL

D6791 1/1/1985 D M

RETAINER CROWN - FULL CAST PREDOMINANTLY BASE

METAL

D6792 1/1/1985 D M RETAINER CROWN - FULL CAST NOBLE METAL

D6793 1/1/2003 D M

PROVISIONAL RETAINER CROWN- FURTHER TREATMENT

OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO

FINAL IMPRESSION

D6794 1/1/2005 D M RETAINER CROWN - TITANIUM AND TITANIUM ALLOYS

D6920 1/1/1996 D M CONNECTOR BAR

D6930 1/1/1985 D M RE-CEMENT OR RE-BOND FIXED PARTIAL DENTURE

D6940 1/1/1985 D M STRESS BREAKER

D6950 1/1/1985 D M PRECISION ATTACHMENT

D6980 1/1/1986 D M

FIXED PARTIAL DENTURE REPAIR NECESSITATED BY

RESTORATIVE MATERIAL FAILURE

D6985 1/1/2003 D M PEDIATRIC PARTIAL DENTURE, FIXED

D6999 1/1/1985 D M

UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE, BY

REPORT

D7140 1/1/2003 D M EXTRACTION, CORONAL REMNANTS - PRIMARY TOOTH

D7210 1/1/1985 D M

EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT

(ELEVATION AND/OR FORCEPS REMOVAL)

D7220 1/1/1985 D M REMOVAL OF IMPACTED TOOTH - SOFT TISSUE

D7230 1/1/1985 D M REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY

D7240 1/1/1985 D M REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY

D7241 1/1/1985 D M

REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY,

WITH UNUSUAL SURGICAL COMPLICATIONS

D7250 1/1/1985 D M

REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING

PROCEDURE)

D7251 1/1/2011 D M

CORONECTOMY - INTENTIONAL PARTIAL TOOTH

REMOVAL

D7270 1/1/1985 D M

TOOTH REIMPLANTATION AND/OR STABILIZATION OF

ACCIDENTALLY EVULSED OR DISPLACED TOOTH

D7272 1/1/1985 D M

TOOTH TRANSPLANTATION (INCLUDES REIMPLANTATION

FROM ONE SITE TO ANOTHER AND SPLINTING AND/OR

STABILIZATION)

D7280 1/1/1985 D M EXPOSURE OF AN UNERUPTED TOOTH

D7282 1/1/2003 D M

MOBILIZATION OF ERUPTED OR MALPOSITIONED TOOTH

TO AID ERUPTION

D7283 1/1/2005 D M

PLACEMENT OF AN ATTACHMENT ON AN UNERUPTED

TOOTH, AGTER ITS EXPOSURE, TO AID IN ITS ERUPTION.

REPORT THE SURGICAL EXPOSURE SEPERATELY USING

D7280.

D7291 1/1/1986 D M

TRANSSEPTAL FIBEROTOMY/SUPRA CRESTAL

FIBEROTOMY, BY REPORT

D7310 1/1/1985 D M

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS -

FOUR OR MORE TEETH OR TOOTH SPACES, PER

QUADRANT

D7311 1/1/2005 D M

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS -

ONE TO THREE TEETH OR TOOTH SPACES, PER

QUANDRANT

D7320 1/1/1985 D M

ALVEOLOPLASTY NOT IN CONJUNCTION WITH

EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH

SPACES, PER QUADRANT

D7321 1/1/2005 D M

ALVEOLOPLASTY NOT IN CONJUNCTION WITH

EXTRACTIONS - ONE TO THREE TEETH OR TOOTH

SPACES, PER QUADRANT

D7340 1/1/1985 D M

VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY

EPITHELIALIZATION)

D7350 1/1/1985 D M

VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING

SOFT TISSUE GRAFTS, MUSCLE REATTACHMENT,

REVISION OF SOFT TISSUE ATTACHMENT AND

MANAGEMENT OF HYPERTROPHIED AND HYPERPLASTIC

TISSUE)

D7510 1/1/1985 D M

INCISION AND DRAINAGE OF ABSCESS - INTRAORAL

SOFT TISSUE

D7511 1/1/2005 D M

INCISION AND DRAINAGE OF ABSCESS - INTRAORAL

SOFT TISSUE - COMPLICATED (INCLUDES DRAINAGE OF

MULTIPLE FASCIAL SPACES)

D7810 1/1/1985 D M OPEN REDUCTION OF DISLOCATION

D7820 1/1/1985 D M CLOSED REDUCTION OF DISLOCATION

D7830 1/1/1985 D M MANIPULATION UNDER ANESTHESIA

D7840 1/1/1985 D M CONDYLECTOMY

D7850 1/1/1985 D M SURGICAL DISCECTOMY, WITH/WITHOUT IMPLANT

D7852 1/1/1992 D M DISC REPAIR

D7854 1/1/1992 D M SYNOVECTOMY

D7856 1/1/1992 D M MYOTOMY

D7858 1/1/1992 D M JOINT RECONSTRUCTION

D7860 1/1/1985 D M ARTHROTOMY

D7865 1/1/1992 D M ARTHROPLASTY

D7870 1/1/1985 D M ARTHROCENTESIS

D7871 1/1/2000 D M NON-ARTHROSCOPIC LYSIS AND LAVAGE

D7872 1/1/1992 D M

ARTHROSCOPY - DIAGNOSTIC, WITH OR WITHOUT

BIOPSY

D7873 1/1/1992 D M ARTHROSCOPY: LAVAGE AND LYSIS OF ADHESIONS

D7874 1/1/1992 D M

ARTHROSCOPY: DISC REPOSITIONING AND

STABILIZATION

D7875 1/1/1992 D M ARTHROSCOPY: SYNOVECTOMY

D7876 1/1/1992 D M ARTHROSCOPY: DISCECTOMY

D7877 1/1/1992 D M ARTHROSCOPY: DEBRIDEMENT

D7880 1/1/1986 D M OCCLUSAL ORTHOTIC DEVICE, BY REPORT

D7881 1/1/2016 D M OCCLUSAL ORTHOTIC DEVICE ADJUSTMENT

D7899 1/1/1992 D M UNSPECIFIED TMD THERAPY, BY REPORT

D7922 1/1/2020 D M

PLACEMENT OF INTRA-SOCKET BIOLOGICAL DRESSING

TO AID IN HEMOSTASIS OR CLOT STABILIZATION, PER

SITE

D7944 1/1/1985 D M OSTEOTOMY - SEGMENTED OR SUBAPICAL

D7945 1/1/1985 D M OSTEOTOMY - BODY OF MANDIBLE

D7946 1/1/1985 D M LEFORT I (MAXILLA - TOTAL)

D7947 1/1/1985 D M LEFORT I (MAXILLA - SEGMENTED)

D7948 1/1/1985 D M

LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL

BONE FOR MIDFACE HYPOPLASIA OR RETRUSION) -

WITHOUT BONE GRAFT

D7950 1/1/1985 D M

OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT

OF THE MANDIBLE OR MAXILLA - AUTOGENOUS OR

NONAUTOGENOUS, BY REPORT

D7960 1/1/1985 D M

FRENULECTOMY - ALSO KNOWN AS FRENECTOMY OR

FRENOTOMY - SEPARATE PROCEDURE NOT INCIDENTAL

TO ANOTHER PROCEDURE

D7963 1/1/2005 D M FRENULOPLASTY

D7971 1/1/1986 D M EXCISION OF PERICORONAL GINGIVAL

D7995 1/1/1996 D M

SYNTHETIC GRAFT - MANDIBLE OR FACIAL BONES, BY

REPORT

D7997 1/1/2000 D M

APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED

APPLIANCE), INCLUDES REMOVAL OF ARCHBAR

D7998 1/1/2007 D M

INTRAORAL PLACEMENT OF A FIXATION DEVICE NOT IN

CONJUNCTION WITH A FRACTURE

D7999 1/1/1985 D M UNSPECIFIED ORAL SURGICAL PROCEDURE, BY REPORT

D8000 1/1/1987 D M INITIAL PAYMENT

D8010 1/1/1996 D M

LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY

DENTITION

D8020 1/1/1996 D M

LIMITED ORTHODONTIC TREATMENT OF THE

TRANSITIONAL DENTITION

D8030 1/1/1996 D M

LIMITED ORTHODONTIC TREATMENT OF THE

ADOLESCENT DENTITION

D8040 1/1/1996 D M

LIMITED ORTHODONTIC TREATMENT OF THE ADULT

DENTITION

D8050 1/1/1996 D M

INTERCEPTIVE ORTHODONTIC TREATMENT OF THE

PRIMARY DENTITION

D8060 1/1/1996 D M

INTERCEPTIVE ORTHODONTIC TREATMENT OF THE


D8070 1/1/1996 D M

COMPREHENSIVE ORTHODONTIC TREATMENT OF THE


D8080 1/1/1996 D M


ADOLESCENT DENTITION

D8090 1/1/1996 D M


ADULT DENTITION

D8099 1/1/1987 D M

ORTHODONTIC RETENTION (REMOVAL OF APPLIANCE,

CONSTRUCTION AND PLACEMENT OF RETAINER(S))

D8210 1/1/1985 D M REMOVABLE APPLIANCE THERAPY

D8220 1/1/1985 D M FIXED APPLIANCE THERAPY

D8660 1/1/1996 D M

PRE-ORTHODONTIC TREATMENT EXAMINATION TO

MONITOR GROWTH AND DEVELOPMENT

D8670 1/1/1996 D M PERIODIC ORTHODONTIC TREATMENT VISIT

D8680 1/1/1996 D M

ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES,

CONSTRUCTION AND PLACEMENT OF RETAINER(S))

D8681 1/1/2016 D M REMOVABLE ORTHODONTIC RETAINER ADJUSTMENT

D8690 1/1/1996 D M

ORTHODONTIC TREATMENT, (ALTERNATIVE BILLING TO A

CONTRACT FEE)

D8695 1/1/2018 D M

REMOVAL OF FIXED ORTHODONTIC APPLIANCES FOR

REASONS OTHER THAN COMPLETION OF TREATMENT

D8696 1/1/2020 D M REPAIR OF ORTHODONTIC APPLIANCE - MAXILLARY

D8697 1/1/2020 D M REPAIR OF ORTHODONTIC APPLIANCE - MANDIBULAR

D8698 1/1/2020 D M RE-CEMENT OR RE-BOND FIXED RETAINER - MAXILLARY

D8699 1/1/2020 D M

RE-CEMENT OR RE-BOND FIXED RETAINER -

MANDIBULAR

D8701 1/1/2020 D M

REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT -

MAXILLARY

D8702 1/1/2020 D M

REPAIR OF FIXED RETAINER, INCLUDES REATTACHMENT -

MANDIBULAR

D8703 1/1/2020 D M

REPLACEMENT OF LOST OR BROKEN RETAINER -

MAXILLARY

D8704 1/1/2020 D M

REPLACEMENT OF LOST OR BROKEN RETAINER -

MANDIBULAR

D8999 1/1/1985 D M UNSPECIFIED ORTHODONTIC PROCEDURE, BY REPORT

D9110 1/1/1985 D M

PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN -

MINOR PROCEDURES

D9120 1/1/2007 D M FIXED PARTIAL DENTURE SECTIONING

D9210 1/1/1985 D M

LOCAL ANESTHESIA NOT IN CONJUNCTION WITH

OPERATIVE OR SURGICAL PROCEDURES

D9211 1/1/1985 D M REGIONAL BLOCK ANESTHESIA

D9212 1/1/1985 D M TRIGEMINAL DIVISION BLOCK ANESTHESIA

D9215 1/1/1985 D M

LOCAL ANESTHESIA IN CONJUNCTION WITH OPERATIVE

OR SURGICAL PROCEDURES

D9219 1/1/2015 D M

EVALUATION FOR MODERATE SEDATION, DEEP

SEDATION OR GENERAL ANESTHESIA

D9222 1/1/2018 D M

DEEP SEDATION/GENERAL ANESTHESIA - FIRST 15

MINUTES

D9223 1/1/2016 D M

DEEP SEDATION/GENERAL ANESTHESIA - EACH

SUBSEQUENT 15 MINUTE INCREMENT

D9230 1/1/1985 D M INHALATION OF NITROUS OXIDE/ANXIOLYSIS, ANALGESIA

D9239 1/1/2018 D M

INTRAVENOUS MODERATE (CONSCIOUS)

SEDATION/ANALGESIA- FIRST 15 MINUTES

D9243 1/1/2016 D M

INTRAVENOUS MODERATE (CONSCIOUS)

SEDATION/ANALGESIA - EACH SUBSEQUENT 15 MINUTE

INCREMENT

D9248 1/1/2000 D M NON-INTRAVENOUS CONSCIOUS SEDATION

D9310 1/1/1985 D M

CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY

DENTIST OR PHYSICIAN OTHER THAN REQUESTING

DENTIST OR PHYSICIAN

D9311 1/1/2017 D M

CONSULTATION WITH A MEDICAL HEALTH CARE

PROFESSIONAL

D9410 1/1/1985 D M HOUSE/EXTENDED CARE FACILITY CALL

D9420 1/1/1985 D M HOSPITAL OR AMBULATORY SURGICAL CENTER CALL

D9430 1/1/1985 D M

OFFICE VISIT FOR OBSERVATION (DURING REGULARLY

SCHEDULED HOURS) - NO OTHER SERVICES

PERFORMED

D9440 1/1/1985 D M OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS

D9450 1/1/2003 D M

CASE PRESENTATION, DETAILED AND EXTENSIVE

TREATMENT PLANNING

D9610 1/1/1985 D M

THERAPEUTIC PARENTERAL DRUG, SINGLE

ADMINISTRATION

D9612 1/1/2007 D M

THERAPEUTIC PARENTERAL DRUGS, TWO OR MORE

ADMINISTRATIONS, DIFFERENT MEDICATIONS

D9613 1/1/2019 D M

INFILTRATION OF SUSTAINED RELEASE THERAPEUTIC

DRUG- SINGLE OR MULTIPLE SITES

D9630 1/1/1985 D M

DRUGS OR MEDICAMENTS DISPENSED IN THE OFFICE

FOR HOME USE

D9910 1/1/1985 D M APPLICATION OF DESENSITIZING MEDICAMENT

D9911 1/1/2000 D M

APPLICATION OF DESENSITIZING RESIN FOR CERVICAL

AND/OR ROOT SURFACE, PER TOOTH

D9920 1/1/1986 D M BEHAVIOR MANAGEMENT, BY REPORT

D9930 1/1/1985 D M

TREATMENT OF COMPLICATIONS (POST-SURGICAL) -

UNUSUAL CIRCUMSTANCES, BY REPORT

D9932 1/1/2016 D M

CLEANING AND INSPECTION OF REMOVABLE COMPLETE

DENTURE, MAXILLARY

D9933 1/1/2016 D M

CLEANING AND INSPECTION OF REMOVABLE COMPLETE

DENTURE, MANDIBULAR

D9934 1/1/2016 D M

CLEANING AND INSPECTION OF REMOVABLE PARTIAL

DENTURE, MAXILLARY

D9935 1/1/2016 D M

CLEANING AND INSPECTION OF REMOVABLE PARTIAL

DENTURE, MANDIBULAR

D9941 1/1/1986 D M FABRICATION OF ATHLETIC MOUTHGUARD

D9942 1/1/2005 D M REPAIR AND/OR RELINE OF OCCLUSAL GUARD

D9943 1/1/2016 D M OCCLUSAL GUARD ADJUSTMENT

D9944 1/1/2019 D M OCCLUSAL GUARD - HARD APPLIANCE, FULL ARCH

D9945 1/1/2019 D M OCCLUSAL GUARD - SOFT APPLIANCE, FULL ARCH

D9946 1/1/2019 D M OCCLUSAL GUARD- HARD APPLIANCE, PARTIAL ARCH

D9950 1/1/1985 D M OCCLUSION ANALYSIS - MOUNTED CASE

D9951 1/1/1986 D M OCCLUSAL ADJUSTMENT - LIMITED

D9952 1/1/1986 D M OCCLUSAL ADJUSTMENT - COMPLETE

D9970 1/1/1996 D M ENAMEL MICROABRASION

D9971 1/1/2000 D M

ODONTOPLASTY 1-2 TEETH; INCLUDES REMOVAL OF

ENAMEL PROJECTIONS

D9972 1/1/2000 D M

EXTERNAL BLEACHING - PER ARCH - PERFORMED IN

OFFICE

D9973 1/1/2000 D M EXTERNAL BLEACHING - PER TOOTH

D9974 1/1/2000 D M INTERNAL BLEACHING - PER TOOTH

D9975 1/1/2013 D M

EXTERNAL BLEACHING FOR HOME APPLICATION, PER

ARCH; INCLUDES MATERIALS AND FABRICATION OF

CUSTOM TRAYS

D9985 1/1/2014 D M SALES TAX

D9986 1/1/2015 D M MISSED APPOINTMENT

D9987 1/1/2015 D M CANCELLED APPOINTMENT

D9991 1/1/2017 D M

DENTAL CASE MANAGEMENT ADDRESSING

APPOINTMENT COMPLIANCE BARRIERS

D9992 1/1/2017 D M DENTAL CASE MANAGEMENT CARE COORDINATION

D9993 1/1/2017 D M

DENTAL CASE MANAGEMENT MOTIVATIONAL

INTERVIEWING

D9994 1/1/2017 D M

DENTAL CASE MANAGEMENT PATIENT EDUCATION TO

IMPROVE ORAL HEALTH LITERACY

D9995 1/1/2018 D M

TELEDENTISTRY - SYNCHRONOUS; REAL-TIME

ENCOUNTER

D9996 1/1/2018 D M

TELEDENTISTRY - ASYNCHRONOUS; INFORMATION

STORED AND FORWARDED TO DENTIST FOR

SUBSEQUENT REVIEW

D9997 1/1/2020 D

DENTAL CASE MANAGEMENT - PATIENTS WITH SPECIAL

HEALTH CARE NEEDS

D9999 1/1/1985 D M UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT

X0005 1/1/1987 D

ANCILLARY DENTAL SERVICE (PRI BUS ONLY - INTERNAL

USE)

X0006 1/1/1987 D

INELIGIBLE DENTAL SERVICE (PRI BUS - INTERNAL USE

ONLY)

X0008 1/1/2016 D

ANCILLARY DENTAL SERVICE (PACHIP FQHC INTERNAL

USE)

XD001 1/1/2014 D

VISION SERVICE ACCUMULATOR - FOR INTERNAL USE

ONLY

XD002 1/1/2014 D RX SERVICE ACCUMULATOR - FOR INTERNAL USE ONLY

XD003 1/1/2014 D

MED SURG SERVICE ACCUMULATOR - FOR INTERNAL

USE ONLY

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