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D2712

Crown – ¾ resin-based composite (indirect)

$

D2720

Crown – resin with high noble metal

$

D2721

Crown – resin with predominantly base metal

$

D2722

Crown – resin with noble metal

$

D2740

Crown – porcelain/ceramic substrate

$

D2750

Crown – porcelain fused to high noble metal

$

D2751

Crown – porcelain fused to predominantly base metal

$

D2752

Crown – porcelain fused to noble metal

$

D2780

Crown – ¾ cast high noble metal

$

D2781

Crown – ¾ cast predominantly base metal

$

D2782

Crown – ¾ cast noble metal

$

D2783

Crown – ¾ porcelain/ceramic

$

D2790

Crown – full cast high noble metal

$

D2791

Crown – full cast predominantly base metal

$

D2792

Crown – full cast noble metal

$

D2794

Crown – titanium

$

D2799

Provisional crown – further treatment or completion of diagnosis necessary prior to final impression

$

D2910

Re–cement or re–bond inlay, onlay, veneer or partial coverage restoration

$

D2915

Re–cement or re–bond indirectly fabricated or prefabricated post and core

$

D2920

Re–cement or re–bond crown

$

D2921

Reattachment of tooth fragment, incisal edge or cusp

$

D2929

Prefabricated porcelain/ceramic crown – primary tooth

$

D2930

Prefabricated stainless steel crown – primary tooth

$

D2931

Prefabricated stainless steel crown – permanent tooth

$

D2932

Prefabricated resin crown

$

D2933

Prefabricated stainless steel crown with resin window

$

D2934

Prefabricated esthetic coated stainless steel crown – primary tooth

$

D2940

Protective restoration

$

D2941

Interim therapeutic restoration – primary dentition

$

D2949

Restorative foundation for an indirect restoration

$

D2950

Core buildup, including any pins when required

$

D2951

Pin retention – per tooth, in addition to restoration

$

D2952

Post and core in addition to crown, indirectly fabricated

$

D2953

Each additional indirectly fabricated post – same tooth

$

D2954

Prefabricated post and core in addition to crown

$

D2955

Post removal

$

D2957

Each additional prefabricated post – same tooth

$

D2960

Labial veneer (resin laminate) – chairside

$

D2961

Labial veneer (resin laminate) – laboratory

$

D2962

Labial veneer (porcelain laminate) – laboratory

$

D2971

Additional procedures to construct new crown under existing partial denture framework

$

D2975

Coping

$

D2980

Crown repair necessitated by restorative material failure

$

D2981

Inlay repair necessitated by restorative material failure

$

D2982

Onlay repair necessitated by restorative material failure

$

D2983

Veneer repair necessitated by restorative material failure

$

D2990

Resin infiltration of incipient smooth surface lesions

$

D2999

Unspecified restorative procedure, by report

$

IV. ENDODONTICS

D3110

Pulp cap – direct (excluding final restoration)

$

D3120

Pulp cap – indirect (excluding final restoration)

$

D3220

Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament

$

D3221

Pulpal debridement, primary and permanent teeth

$

D3222

Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development

$

D3230

Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)

$

D3240

Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)

$

D3310

Endodontic therapy, anterior tooth (excluding final restoration)

$

D3320

Endodontic therapy, bicuspid tooth (excluding final restoration)

$

D3330

Endodontic therapy, molar (excluding final restoration)

$

D3331

Treatment of root canal obstruction; non-surgical access

$

D3332

Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

$

D3333

Internal root repair of perforation defects

$

D3346

Retreatment of previous root canal therapy – anterior

$

D3347

Retreatment of previous root canal therapy – bicuspid

$

D3348

Retreatment of previous root canal therapy – molar

$

D3351

Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

$

D3352

Apexification/recalcification – interim medication replacement

$

D3353

Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.)

$

D3355

Pulpal regeneration – initial visit

$

D3356

Pulpal regeneration – interim medication replacement

$

D3357

Pulpal regeneration – completion of treatment

$

D3410

Apicoectomy – anterior

$

D3421

Apicoectomy – bicuspid (first root)

$

D3425

Apicoectomy – molar (first root)

$

D3426

Apicoectomy (each additional root)

$

D3427

Periradicular surgery without apicoectomy

$

D3428

Bone graft in conjunction with periradicular surgery – per tooth, single site

$

D3429

Bone graft in conjunction with periradicular surgery – each additional contiguous tooth in the same surgical site

$

D3430

Retrograde filling – per root

$

D3431

Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery

$

D3432

Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery

$

D3450

Root amputation – per root

$

D3460

Endodontic endosseous implant

$

D3470

Intentional re-implantation (including necessary splinting)

$

D3910

Surgical procedure for isolation of tooth with rubber dam

$

D3920

Hemisection (including any root removal), not including root canal therapy

$

D3950

Canal preparation and fitting of preformed dowel or post

$

D3999

Unspecified endodontic procedure, by report

$

V. PERIODONTICS

D4210

Gingivectomy or gingivoplasty -four or more contiguous teeth or tooth bounded spaces per quadrant

$

D4211

Gingivectomy or gingivoplasty –one to three contiguous teeth or tooth bounded spaces per quadrant

$

D4212

Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

$

D4230

Anatomical crown exposure – four or more contiguous teeth per quadrant

$

D4231

Anatomical crown exposure – one to three teeth per quadrant

$

D4240

Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant

$

D4241

Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant

$

D4245

Apically positioned flap

$

D4249

Clinical crown lengthening – hard tissue

$

D4260

Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant

$

D4261

Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant

$

D4263

Bone replacement graft – first site in quadrant

$

D4264

Bone replacement graft – each additional site in quadrant

$

D4265

Biologic materials to aid in soft and osseous tissue regeneration

$

D4266

Guided tissue regeneration – resorbable barrier, per site

$

D4267

Guided tissue regeneration – non-resorbable barrier, per site (includes membrane removal)

$

D4268

Surgical revision procedure, per tooth

$

D4270

Pedicle soft tissue graft procedure

$

D4273

Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or endentulous tooth position

$

D4274

Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area)

$

D4275

Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant or endentulous tooth position in graft

$

D4276

Combined connective tissue and double pedicle graft, per tooth

$

D4277

Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or endentulous tooth position in graft

$

D4278

Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or endentulous tooth position in same graft site

$

D4283

Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or endenulous tooth position in same graft site

$

D4285

Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or endenulous tooth position in same graft site

$

D4320

Provisional splinting – intracoronal

$

D4321

Provisional splinting – extracoronal

$

D4341

Periodontal scaling and root planing – four or more teeth per quadrant

$

D4342

Periodontal scaling and root planing – one to three teeth per quadrant

$

D4355

Full mouth debridement to enable comprehensive evaluation and diagnosis

$

D4381

Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

$

D4910

Periodontal maintenance

$

D4920

Unscheduled dressing change (by someone other than treating dentist or their staff)

$

D4921

Gingival irrigation – per quadrant

$

D4999

Unspecified periodontal procedure, by report

$

VI. PROSTHODONTICS (REMOVABLE)

D5110

Complete denture – maxillary

$

D5120

Complete denture – mandibular

$

D5130

Immediate denture – maxillary

$

D5140

Immediate denture – mandibular

$

D5211

Maxillary partial denture – resin base (including any conventional clasps, rests and teeth)

$

D5212

Mandibular partial denture – resin base (including any conventional clasps, rests and teeth)

$

D5213

Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

$

D5214

Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

$

D5221

Immediate maxillary partial denture – resin base (including any conventional clasps, rests and teeth)

$

D5222

Immediate mandibular partial denture – resin base (including any conventional clasps, rests and teeth)

$

D5223

Immediate maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)

$

D5224

Immediate mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth)

$

D5225

Maxillary partial denture – flexible base (including any clasps, rests and teeth)

$

D5226

Mandibular partial denture – flexible base (including any clasps, rests and teeth)

$

D5281

Removable unilateral partial denture – one piece cast metal (including clasps and teeth)

$

D5410

Adjust complete denture – maxillary

$

D5411

Adjust complete denture – mandibular

$

D5421

Adjust partial denture – maxillary

$

D5422

Adjust partial denture – mandibular

$

D5510

Repair broken complete denture base

$

D5520

Replace missing or broken teeth – complete denture (each tooth)

$

D5610

Repair resin denture base

$

D5620

Repair cast framework

$

D5630

Repair or replace broken clasp – per tooth

$

D5640

Replace broken teeth – per tooth

$

D5650

Add tooth to existing partial denture

$

D5660

Add clasp to existing partial denture – per tooth

$

D5670

Replace all teeth and acrylic on cast metal framework (maxillary)

$

D5671

Replace all teeth and acrylic on cast metal framework (mandibular)

$

D5710

Rebase complete maxillary denture

$

D5711

Rebase complete mandibular denture

$

D5720

Rebase maxillary partial denture

$

D5721

Rebase mandibular partial denture

$

D5730

Reline complete maxillary denture (chairside)

$

D5731

Reline complete mandibular denture (chairside)

$

D5740

Reline maxillary partial denture (chairside)

$

D5741

Reline mandibular partial denture (chairside)

$

D5750

Reline complete maxillary denture (laboratory)

$

D5751

Reline complete mandibular denture (laboratory)

$

D5760

Reline maxillary partial denture (laboratory)

$

D5761

Reline mandibular partial denture (laboratory)

$

D5810

Interim complete denture (maxillary)

$

D5811

Interim complete denture (mandibular)

$

D5820

Interim partial denture (maxillary)

$

D5821

Interim partial denture (mandibular)

$

D5850

Tissue conditioning, maxillary

$

D5851

Tissue conditioning, mandibular

$

D5862

Precision attachment, by report

$

D5863

Overdenture – complete maxillary

$

D5864

Overdenture – partial maxillary

$

D5865

Overdenture – complete mandibular

$

D5866

Overdenture – partial mandibular

$

D5867

Replacement of replaceable part of semi-precision or precision attachment (male or female component)

$

D5875

Modification of removable prosthesis following implant surgery

$

D5899

Unspecified removable prosthodontic procedure, by report

$

VII. MAXILLOFACIAL PROSTHETICS

D5911

Facial moulage (sectional)

$

D5912

Facial moulage (complete)

$

D5913

Nasal prosthesis

$

D5914

Auricular prosthesis

$

D5915

Orbital prosthesis

$

D5916

Ocular prosthesis

$

D5919

Facial prosthesis

$

D5922

Nasal septal prosthesis

$

D5923

Ocular prosthesis, interim

$

D5924

Cranial prosthesis

$

D5925

Facial augmentation implant prosthesis

$

D5926

Nasal prosthesis, replacement

$

D5927

Auricular prosthesis, replacement

$

D5928

Orbital prosthesis, replacement

$

D5929

Facial prosthesis, replacement

$

D5931

Obturator prosthesis, surgical

$

D5932

Obturator prosthesis, definitive

$

D5933

Obturator prosthesis, modification

$

D5934

Mandibular resection prosthesis with guide flange

$

D5935

Mandibular resection prosthesis without guide flange

$

D5936

Obturator prosthesis, interim

$

D5937

Trismus appliance (not for TMD treatment)

$

D5951

Feeding aid

$

D5952

Speech aid prosthesis, pediatric

$

D5953

Speech aid prosthesis, adult

$

D5954

Palatal augmentation prosthesis

$

D5955

Palatal lift prosthesis, definitive

$

D5958

Palatal lift prosthesis, interim

$

D5959

Palatal lift prosthesis, modification

$

D5960

Speech aid prosthesis, modification

$

D5982

Surgical stent

$

D5983

Radiation carrier

$

D5984

Radiation shield

$

D5985

Radiation cone locator

$

D5986

Fluoride gel carrier

$

D5987

Commissure splint

$

D5988

Surgical splint

$

D5991

Vesiculobullous disease medicament carrier

$

D5992

Adjust maxillofacial prosthetic appliance, by report

$

D5993

Maintenance and cleaning of a maxillofacial prosthesis (extra- or intra-oral) other than required adjustments, by report

$

D5994

Periodontal medicament carrier with peripheral seal – laboratory processed

$

D5999

Unspecified maxillofacial prosthesis, by report

$
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