D0120
|
Periodic oral evaluation—established patient
|
50
|
D0140
|
Limited oral evaluation—problem focused
|
75
|
D0145
|
Oral evaluation—patient under 3yrs & counseling with primary caregiver
|
69
|
D0150
|
Comprehensive oral evaluation—new or established patient
|
88
|
D0160
|
Detailed & Extensive oral evaluation—problem focused, by report
|
160
|
D0170
|
Re-evaluation—limited, problem focused (established patient; not post-operative visit
|
70
|
D0180
|
Comprehensive periodontal evaluation—new or established patient
|
95
|
D0210
|
Intraoral—complete series (including bitewings)
|
128
|
D0220
|
Intraoral—periapical first film
|
28
|
D0230
|
Intraoral—periapical each additional film
|
24
|
D0240
|
Intraoral—occlusal films
|
42
|
D0250
|
Intraoral—first film
|
67
|
D0260
|
Extraoral—first film
|
55
|
D0270
|
Bitewing—single film
|
28
|
D0272
|
Bitewing—two films
|
45
|
D0273
|
Bitewing—three films
|
55
|
D0274
|
Bitewing—four films
|
65
|
D0277
|
Vertical bitewings—7 to 8 films
|
97
|
D0290
|
Posterior-anterior or lateral skull & facial bone survey film
|
135
|
D0310
|
Sialography
|
389
|
D0320
|
Temporomandibular joint films, including injection
|
592
|
D0321
|
Other temporomandibular joint films, by report
|
210
|
D0322
|
Tomographic survey
|
530
|
D0330
|
Panoramic film
|
110
|
D0340
|
Cephalometric film
|
125
|
D0350
|
Oral/facial photographic images
|
71
|
D0360
|
Cone beam CT—craniofacial data capture
|
589
|
D0362
|
Cone beam CT—two-dimensional image reconstruction using existing data, includes multiple images
|
359
|
D0363
|
Cone beam CT—three-dimensional image reconstruction using existing data, includes multiple images
|
398
|
D0415
|
Collection of microorganisms for culture and sensitivity
|
186
|
D0416
|
Viral culture
|
168
|
D0417
|
Collection and preparation of saliva sample for laboratory diagnostic testing
|
167
|
D0418
|
Analysis of saliva sample
|
150
|
D0421
|
Genetic test for susceptibility to oral diseases
|
136
|
D0425
|
Caries susceptibility tests
|
95
|
D0431
|
Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
|
71
|
D0460
|
Pulp vitality tests
|
55
|
D0470
|
Diagnostic casts
|
109
|
D0472
|
Accession of tissue, gross examination, preparation and transmission of written report
|
118
|
D0473
|
Accession of tissue, gross examination and microscopic examination, preparation and transmission of written report
|
165
|
D0474
|
Accession of tissue, gross examination and microscopic examination including assessment of surgical margins for presence of disease, preparation and transmission of written report
|
184
|
D0480
|
Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report
|
176
|
D0486
|
Accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report
|
150
|
D0475
|
Decalcification procedure
|
195
|
D0476
|
Special stains for microorganisms
|
289
|
D0477
|
Special stains not for microorganisms
|
296
|
D0478
|
Immunohistochemical stains
|
175
|
D0479
|
Tissue in-situ hybridization, including interpretation
|
231
|
D0481
|
Electron microscopy—diagnostic
|
188
|
D0482
|
Direct immunofluorescence
|
105
|
D0483
|
Indirect immunofluorescence
|
123
|
D0484
|
Consultation on slides prepared elsewhere
|
168
|
D0485
|
Consultation, including preparation of slides from biopsy material supplied by referring source
|
180
|
D0502
|
Other oral pathology procedures, by report
|
170
|
D0999
|
Unspecified diagnostic procedure, by report
|
IR
|
D1110
|
Prophylaxis—adult
|
90
|
D1120
|
Prophylaxis—child
|
66
|
D1203
|
Topical application of fluoride—child
|
37
|
D1204
|
Topical application of fluoride—adult
|
37
|
D1206
|
Topical fluoride varnish; therapeutic application for moderate to high caries risk patients
|
45
|
D1310
|
Nutritional counseling for control of dental disease
|
70
|
D1320
|
Tobacco counseling for the control and prevention of oral disease
|
82
|
D1330
|
Oral hygiene instructions
|
55
|
D1351
|
Sealant—per tooth
|
54
|
D1352
|
Preventative resin restoration in a moderate to high caries risk patient—permanent tooth
|
IR
|
D1510
|
Space maintainer—fixed—unilateral
|
317
|
D1515
|
Space maintainer—fixed—bilateral
|
432
|
D1520
|
Space maintainer—removable—unilateral
|
390
|
D1525
|
Space maintainer—removable—bilateral
|
495
|
D1550
|
Re-cementation of space maintainer
|
83
|
D1555
|
Removal of fixed space maintainer
|
79
|
D2140
|
Amalgam—one surface, primary or permanent
|
138
|
D2150
|
Amalgam—two surfaces, primary or permanent
|
176
|
D2160
|
Amalgam—three surfaces, primary or permanent
|
214
|
D2161
|
Amalgam—four surfaces, primary or permanent
|
251
|
D2330
|
Resin-based composite—one surface, anterior
|
160
|
D2331
|
Resin-based composite—two surfaces, anterior
|
200
|
D2332
|
Resin-based composite—three surfaces, anterior
|
249
|
D2335
|
Resin-based composite—four or more surfaces or involving incisal angle (anterior)
|
312
|
D2390
|
Resin-based composite crown—anterior
|
450
|
D2391
|
Resin-based composite—one surface, posterior
|
177
|
D2392
|
Resin-based composite—two surfaces, posterior
|
230
|
D2393
|
Resin-based composite—three surfaces, posterior
|
284
|
D2394
|
Resin-based composite—four or more surfaces posterior
|
341
|
D2410
|
Gold foil—one surface
|
635
|
D2420
|
Gold foil—two surfaces
|
692
|
D2430
|
Gold foil—three surfaces
|
806
|
D2510
|
Inlay—metallic—one surface
|
833
|
D2520
|
Inlay—metallic—two surfaces
|
892
|
D2530
|
Inlay—metallic—three or more surfaces
|
965
|
D2542
|
Onlay—metallic—two surfaces
|
990
|
D2543
|
Onlay—metallic—three surfaces
|
1015
|
D2544
|
Onlay—metallic—four or more surfaces
|
1050
|
D2610
|
Inlay—porcelain/ceramic—one surface
|
907
|
D2620
|
Inlay—porcelain/ceramic—two surfaces
|
950
|
D2630
|
Inlay—porcelain/ceramic—three or more surfaces
|
995
|
D2642
|
Onlay—porcelain/ceramic—two surfaces
|
1008
|
D2643
|
Onlay—porcelain/ceramic—three surfaces
|
1049
|
D2644
|
Onlay—porcelain/ceramic—four or more surfaces
|
1094
|
D2650
|
Inlay—resin based—one surface
|
869
|
D2651
|
Inlay—resin based—two surfaces
|
904
|
D2652
|
Inlay—resin based—three or more surfaces
|
940
|
D2662
|
Onlay—resin based—two surfaces
|
944
|
D2663
|
Onlay—resin based—three surfaces
|
983
|
D2664
|
Onlay—resin based—four or more surfaces
|
1025
|
D2710
|
Crown—resin-based composite (indirect)
|
940
|
D2712
|
Crown—3/4 resin-based composite (indirect)
|
999
|
D2720
|
Crown—resin with high noble metal
|
1061
|
D2721
|
Crown—resin with predominantly base metal
|
998
|
D2722
|
Crown—resin with noble metal
|
1015
|
D2740
|
Crown—porcelain/ceramic substrate
|
1132
|
D2750
|
Crown—porcelain fused to high noble metal
|
1100
|
D2571
|
Crown—porcelain fused predominantly base metal
|
1029
|
D2752
|
Crown—porcelain fused to noble metal
|
1050
|
D2780
|
Crown—3/4 cast high noble metal
|
1063
|
D2781
|
Crown—3/4 cast predominantly base metal
|
1027
|
D2782
|
Crown—3/4 cast noble metal
|
1030
|
D2783
|
Crown—3/4 porcelain /ceramic
|
1100
|
D2790
|
Crown—full cast high noble metal
|
1100
|
D2791
|
Crown—full cast predominantly base metal
|
997
|
D2792
|
Crown—full cast noble metal
|
1045
|
D2794
|
Crown—titanium
|
1076
|
D2799
|
Provisional crown
|
437
|
D2910
|
Recement inlay, only, or partial coverage restoration
|
108
|
D2915
|
Recement cast or prefabricated post and core
|
114
|
D2920
|
Recement crown
|
109
|
D2930
|
Prefabricated stainless steel crown—primary tooth
|
271
|
D2931
|
Prefabricated stainless steel crown—permanent tooth
|
325
|
D2932
|
Prefabricated resin crown
|
351
|
D2933
|
Prefabricated stainless steel crown with resin window
|
363
|
D2934
|
Prefabricated esthetic coated stainless tell crown—primary tooth
|
372
|
D2940
|
Protective restoration
|
120
|
D2950
|
Core buildup, including any pins
|
271
|
D2951
|
Pin retention—per tooth, in addition to restoration
|
75
|
D2952
|
Post and core in addition to crown, indirectly fabricated
|
422
|
D2953
|
Each additional indirectly fabricated post—same tooth
|
312
|
