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I. DIAGNOSTIC

D0120

Periodic oral evaluation – established patient

$

D0140

Limited oral evaluation – problem focused

$

D0145

Oral evaluation for a patient under three years of age and counseling with primary caregiver

$

D0150

Comprehensive oral evaluation – new or established patient

$

D0160

Detailed and extensive oral evaluation – problem focused, by report

$

D0170

Re–evaluation – limited, problem focused (established patient; not post-operative visit)

$

D0171

Re–evaluation – post-operative office visit

$

D0180

Comprehensive periodontal evaluation – new or established patient

$

D0190

Screening of a patient

$

D0191

Assessment of a patient

$

D0210

Intraoral – complete series of radiographic images

$

D0220

Intraoral – periapical first radiographic image

$

D0230

Intraoral – periapical each additional radiographic image

$

D0240

Intraoral – occlusal radiographic image

$

D0250

Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector

$

D0251

Extra-oral posterior dental radiographic image

$

D0270

Bitewing – single radiographic image

$

D0272

Bitewings – two radiographic images

$

D0273

Bitewings – three radiographic images

$

D0274

Bitewings – four radiographic images

$

D0277

Vertical bitewings – 7 to 8 radiographic images

$

D0290

Posterior–anterior or lateral skull and facial bone survey radiographic image

$

D0310

Sialography

$

D0320

Temporomandibular joint arthrogram, including injection

$

D0321

Other temporomandibular joint radiographic images, by report

$

D0322

Tomographic survey

$

D0330

Panoramic radiographic image

$

D0340

2D cephalometric radiographic image – acquisition, measurement and analysis

$

D0350

2D oral/facial photographic image obtained intra-orally or extra-orally

$

D0351

3D photographic image

$

D0364

Cone beam CT capture and interpretation with limited field of view – less than one whole jaw

$


D0365

Cone beam CT capture and interpretation with field of view of one full dental arch – mandible

$

D0366

Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium

$

D0367

Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium

$

D0368

Cone beam CT capture and interpretation for TMJ series including two or more exposures

$

D0369

Maxillofacial MRI capture and interpretation

$

D0370

Maxillofacial ultrasound capture and interpretation

$

D0371

Sialoendoscopy capture and interpretation

$

D0380

Cone beam CT image capture with limited field of view – less than one whole jaw

$

D0381

Cone beam CT image capture with field of view of one full dental arch – mandible

$

D0382

Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium

$

D0383

Cone beam CT image capture with field of view of both jaws, with or without cranium

$

D0384

Cone beam CT image capture for TMJ series including two or more exposures

$

D0385

Maxillofacial MRI image capture

$

D0386

Maxillofacial ultrasound image capture

$

D0391

Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

$

D0393

Treatment simulation using 3D image volume

$

D0394

Digital subtraction of two or more images or image volumes of the same modality

$

D0395

Fusion of two or more 3D image volumes of one or more modalities

$

D0415

Collection of microorganisms for culture and sensitivity

$

D0416

Viral culture

$

D0417

Collection and preparation of saliva sample for laboratory diagnostic testing

$

D0418

Analysis of saliva sample

$

D0422

Collection and preparation of genetic sample material for laboratory analysis and report

$

D0423

Genetic test for susceptibility to diseases – specimen analysis

$

D0425

Caries susceptibility tests

$

D0431

Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

$

D0460

Pulp vitality tests

$

D0470

Diagnostic casts

$

D0472

Accession of tissue, gross examination, preparation and transmission of written report

$

D0473

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

$

D0474

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

$

D0475

Decalcification procedure

$

D0476

Special stains for microorganisms

$

D0477

Special stains, not for microorganisms

$

D0478

Immunohistochemical stains

$

D0479

Tissue in-situ hybridization, including interpretation

$

D0480

Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

$

D0481

Electron microscopy

$

D0482

Direct immunofluorescence

$

D0483

Indirect immunofluorescence

$

D0484

Consultation on slides prepared elsewhere

$

D0485

Consultation, including preparation of slides from biopsy material supplied by referring source

$

D0486

Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

$

D0502

Other oral pathology procedures, by report

$

D0601

Caries risk assessment and documentation, with a finding of low risk

$

D0602

Caries risk assessment and documentation, with a finding of moderate risk

$

D0603

Caries risk assessment and documentation, with a finding of high risk

$

D0999

Unspecified diagnostic procedure, by report

$

II. PREVENTIVE

D1110

Prophylaxis – adult

$

D1120

Prophylaxis – child

$

D1206

Topical application of fluoride varnish

$

D1208

Topical application of fluoride -excluding varnish

$

D1310

Nutritional counseling for control of dental disease

$

D1320

Tobacco counseling for the control and prevention of oral disease

$

D1330

Oral hygiene instructions

$

D1351

Sealant – per tooth

$

D1352

Preventive resin restoration in a moderate to high caries risk patient – permanent tooth

$

D1353

Sealant repair – per tooth

$

D1354

Interim caries arresting medicament application

$

D1510

Space maintainer – fixed – unilateral

$

D1515

Space maintainer – fixed –bilateral

$

D1520

Space maintainer – removable –unilateral

$

D1525

Space maintainer – removable –bilateral

$

D1550

Re–cement or re–bond space maintainer

$

D1555

Removal of fixed space maintainer

$

D1999

Unspecified preventive procedure, by report

$

III. RESTORATIVE

D2140

Amalgam – one surface, primary or permanent

$

D2150

Amalgam – two surfaces, primary or permanent

$

D2160

Amalgam – three surfaces, primary or permanent

$

D2161

Amalgam – four or more surfaces, primary or permanent

$

D2330

Resin-based composite – one surface, anterior

$

D2331

Resin-based composite – two surfaces, anterior

$

D2332

Resin-based composite – three surfaces, anterior

$

D2335

Resin-based composite – four or more surfaces or involving incisal angle (anterior)

$

D2390

Resin-based composite crown, anterior

$

D2391

Resin-based composite – one surface, posterior

$

D2392

Resin-based composite – two surfaces, posterior

$

D2393

Resin-based composite – three surfaces, posterior

$

D2394

Resin-based composite – four or more surfaces, posterior

$

D2410

Gold foil – one surface

$

D2420

Gold foil – two surfaces

$

D2430

Gold foil – three surfaces

$

D2510

Inlay – metallic – one surface

$

D2520

Inlay – metallic – two surfaces

$

D2530

Inlay – metallic – three or more surfaces

$

D2542

Onlay – metallic – two surfaces

$

D2543

Onlay – metallic – three surfaces

$

D2544

Onlay – metallic – four or more surfaces

$

D2610

Inlay – porcelain/ceramic – one surface

$

D2620

Inlay – porcelain/ceramic – two surfaces

$

D2630

Inlay – porcelain/ceramic – three or more surfaces

$

D2642

Onlay – porcelain/ceramic – two surfaces

$

D2643

Onlay – porcelain/ceramic – three surfaces

$

D2644

Onlay – porcelain/ceramic – four or more surfaces

$

D2650

Inlay – resin-based composite –one surface

$

D2651

Inlay – resin-based composite – two surfaces

$

D2652

Inlay – resin-based composite – three or more surfaces

$

D2662

Onlay – resin-based composite – two surfaces

$

D2663

Onlay – resin-based composite – three surfaces

$

D2664

Onlay – resin-based composite – four or more surfaces

$

D2710

Crown – resin-based composite (indirect)

$
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