Transcription
CDT 2952D2954D3310D3320D3330D3346D3347D3348CDT tist effective07/01/18Non-participatingDentistCrown - porcelain/ceramic substrate686.00185.00Crown - porcelain fused to high noble metal614.00180.00Crown - porcelain fused to predominantly base metal546.00160.00Crown - porcelain fused to noble metal617.00170.00Crown - 3/4 cast high noble metal595.00165.00Crown - 3/4 porcelain/ceramic708.00160.00Crown - full cast high noble metal630.00170.00Crown - full cast predominantly base metal523.00145.00Crown - full cast noble metal556.00160.00Post and core in addition to crown, indirectly fabricated209.0060.00Prefabricated post and core in addition to crown162.0040.00Endodontic therapy, anterior tooth (excluding final restoration)488.00418.00Endodontic therapy, bicuspid premolar tooth (excluding final restoration)615.00495.00Endodontic therapy, molar tooth (excluding final restoration)755.00651.00Retreatment of previous root canal therapy - anterior620.00555.00Retreatment of previous root canal therapy - bicuspid premolar782.00632.00Retreatment of previous root canal therapy -880.00768.00ParticipatingDentist effective07/01/18Non-participatingDentistSurgical placement of implant body: endosteal implant985.00225.00Second stage implant surgery385.00110.001,466.00335.00Prefabricated abutment - includes modification and placement420.0096.00Custom fabricated abutment - includes placement579.00133.00Abutment supported porcelain/ceramic crown810.00185.00Abutment supported porcelain fused to metal crown (high noble metal)829.00180.001,143.00160.00Abutment supported porcelain fused to metal crown (noble metal)659.00170.00Abutment supported cast metal crown (high noble metal)776.00170.00Abutment supported cast metal crown (noble metal)700.00160.00Implant supported porcelain/ceramic crown875.00185.00Implant supported porcelain fused to metal crown (titanium, titanium alloy, highnoble metal)837.00180.00Implant supported metal crown (titanium, titanium alloy, high noble metal)837.00170.00Abutment supported retainer for porcelain/ceramic FPD810.00185.00Abutment supported retainer for porcelain fused to metal FPD (high noble metal)859.00180.00Enhanced Fee Codes for CrownsEnhanced Fee Codes for ImplantsSurgical placement: transosteal implantAbutment supported porcelain fused to metal crown (predominantly base metal)Updated 01/01/18CDT 18Page 1 of 25
D6190CDT butment supported retainer for porcelain fused to metal FPD (noble metal)659.00170.00Abutment supported retainer for cast metal FPD (high noble metal)818.00170.00Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy,or high noble metal)859.00180.00Recement or re-bond implant/abutment supported crown98.0028.00Recement or re-bond implant/abutment supported fixed partial denture137.0039.00Abutment supported crown (titanium)818.00170.00Repair implant abutment, by report252.0072.00Bone graft at time of implant placement389.00111.00Implant/abutment supported removable denture for edentulous arch - maxillary1,046.00231.00Implant/abutment supported removable denture for edentulous arch - ntist 6.0022.004.00ParticipatingDentist effective07/01/18Non-participatingDentistDeep sedation/general anesthesia – each subsequent 15 minute increment138.00103.00Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minuteincrement138.0093.00Radiographic/surgical implant index, by reportEnhanced Fee Codes for OrthodonticsLimited orthodontic treatment of the transitional dentition - Considered under age19Limited orthodontic treatment of the adolescent dentition - Considered under age19Interceptive orthodontic treatment of the transitional dentition - Considered underage 19Comprehensive orthodontic treatment of the transitional dentition -Consideredunder age 19Comprehensive orthodontic treatment of the adolescent dentition - Consideredunder age 19Comprehensive orthodontic treatment of the adult dentition - Considered under age19Pre-orthodontic treatment examination to monitor growth and development Considered under age 19Periodic orthodontic treatment visit - Considered under age 19Orthodontic retention (removal of appliances, construction and placement ofretainer(s)) - Considered under age 19Removable orthodontic retainer adjustment - Considered under age 19D8681CDT CodeD9223D9243Enhanced Fee Codes for Oral SurgeryUpdated 01/01/18CDT 18Page 2 of 25
ParticipatingDentist effective07/01/18Non-participatingDentistPeriodic oral evaluation - established patient24.0024.00Limited Oral Evaluation - problem focused38.0038.00Oral evaluation for a patient under three years of age and counseling with primarycaregiver39.0039.00Comprehensive oral evaluation - new or established patient39.0039.00Comprehensive periodontal evaluation - new or established patient39.0039.00Intraoral - complete series of radiographic images75.0075.00Intraoral - periapical first radiographic image15.0015.00Intraoral - periapical each addition radiographic image9.009.00Intraoral - occlusal radiographic image20.0020.00Bitewing - single radiographic image17.0017.00Bitewings - two radiographic images22.0022.00Bitewings - three radiographic images24.0024.00Bitewings - four radiographic images34.0034.00Vertical bitewings - 7 to 8 radiographic images44.0044.00Panoramic radiographic image63.0063.00Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalitiesincluding premalignant and malignant lesions, not to include cytology or biopsyprocedures28.0028.00Diagnostic casts11.0011.00Prophylaxis - Adult53.0053.00Prophylaxis - Child38.0038.00Topical application of fluoride varnish19.0019.00Topical application of fluoride - excluding varnish19.0019.00Sealant - per tooth27.0027.00Preventive resin restoration in a moderate to high caries risk patient - permanenttooth.27.0027.00Space maintainer - fixed - unilateral194.00194.00Space maintainer - fixed - bilateral303.00303.00Space maintainer - removable - unilateral180.00180.00Space maintainer - removable - bilateral282.00282.00Re-cement or re-bond space maintainer37.0037.00Removal of fixed space maintainer25.0025.00Distal shoe space maintainer - fixed - unilateral194.00194.00Distal shoe space maintainer - fixed - unilateral194.00194.00Amalgam - one surface, primary or permanent58.0058.00Amalgam - two surfaces, primary or permanent77.0077.00Amalgam - three surfaces, primary or permanent98.0098.00Amalgam - four or more surfaces, primary or permanent117.00117.00All Covered ProceduresCDT 1575D1575D2140D2150D2160D2161Updated 01/01/18CDT 18Page 3 of 25
-based composite - one surface, anterior77.0077.00Resin-based composite - two surfaces, anterior107.00107.00Resin-based composite - three surfaces, anterior117.00117.00Resin-based composite - four or more surfaces or involving incisal angle (anterior)126.00126.00Resin-based composite - one surface - posterior58.0058.00Resin-based composite - two surfaces - posterior77.0077.00Resin-based composite - three surfaces - posterior98.0098.00Resin-based composite - four or more surfaces - posterior117.00117.00Inlay - metallic - one surface300.00110.00Inlay - metallic - two surfaces355.00130.00Inlay - metallic - three or more surfaces382.00140.00Onlay - metallic - two surfaces437.00160.00Onlay - metallic - three surfaces437.00160.00Onlay - metallic - four or more surfaces450.00165.00Inlay - porcelain/ceramic - one surface273.00100.00Inlay - porcelain/ceramic - two surfaces355.00130.00Inlay - porcelain/ceramic - three or more surfaces396.00145.00Onlay - porcelain/ceramic - two surfaces382.00140.00Onlay - porcelain/ceramic - three surfaces437.00160.00Onlay - porcelain/ceramic - four or more surfaces464.00170.00Inlay - resin-based composite - one surface232.0085.00Inlay - resin-based composite - two surfaces314.00115.00Inlay - resin-based composite - three or more surfaces341.00125.00Onlay - resin-based composite - two surfaces328.00120.00Onlay - resin-based composite - three surfaces382.00140.00Onlay - resin-based composite - four or more surfaces396.00145.00Crown - resin-based composite (indirect)341.00125.00Crown - 3/4 resin-based composite (indirect)341.00125.00Crown - resin with high noble metal437.00160.00Crown - resin with predominantly base metal355.00130.00Crown - resin with noble metal396.00145.00Crown - porcelain/ceramic substrate686.00185.00Crown - porcelain fused to high noble metal614.00180.00Crown - porcelain fused to predominantly base metal546.00160.00Crown - porcelain fused to noble metal617.00170.00Crown - 3/4 cast high noble metal595.00165.00Crown - 3/4 cast predominantly base metal410.00150.00Crown - 3/4 cast noble metal423.00155.00Crown - 3/4 porcelain/ceramic708.00160.00Updated 01/01/18CDT 18Page 4 of 25
D3221D3222D3230D3240D3310D3320D3330D3346D3347Crown - full cast high noble metal630.00170.00Crown - full cast predominantly base metal523.00145.00Crown - full cast noble metal556.00160.00Crown - titanium464.00170.00Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration49.0049.00Re-cement or re-bond indirectly fabricated or prefabricated post and core49.0049.00Re-cement or re-bond crown49.0049.00Prefabricated porcelain/ceramic crown - primary tooth194.00194.00Prefabricated stainless steel crown - primary tooth156.00156.00Prefabricated stainless steel crown - permanent tooth165.00165.00Prefabricated resin crown303.00111.00Prefabricated stainless steel crown with resin window303.00111.00Prefabricated esthetic coated stainless steel crown - primary tooth194.00194.00Protective restoration49.0049.00Interim therapeutic restoration - primary dentition35.0035.00Core buildup, including any pins when required68.0025.00Pin retention - per tooth, in addition to restoration26.0026.00Post and core in addition to crown, indirectly fabricated209.0060.00Prefabricated post and core in addition to crown162.0040.00Labial veneer (resin laminate) - chairside328.00120.00Labial veneer (resin laminate) - laboratory491.00180.00Labial veneer (porcelain laminate) - laboratory696.00255.00Crown repair necessitated by restorative material failure74.0074.00Inlay repair necessitated by restorative material failure74.0074.00Onlay repair necessitated by restorative material failure74.0074.00Veneer repair necessitated by restorative material failure74.0074.00Resin infiltration of incipient smooth surface lesions12.0012.00Pulp cap - direct (excluding final restoration)30.0030.00Pulp cap - indirect (excluding final restoration)30.0030.00Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to thedentinocemental junction and application of medicament98.0098.00Pulpal debridement, primary and permanent teeth98.0098.00Partial pulpotomy for apexogenesis - permanent tooth with incomplete rootdevelopmentPulpal therapy (resorbable filling) - anterior, primary tooth (excluding finalrestoration)Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding 0Endodontic therapy, anterior tooth (excluding final restoration)488.00418.00Endodontic therapy, bicuspid premolar tooth (excluding final restoration)615.00495.00Endodontic therapy, molar tooth (excluding final restoration)755.00651.00Retreatment of previous root canal therapy - anterior620.00555.00Retreatment of previous root canal therapy - bicuspid premolar782.00632.00Updated 01/01/18CDT 18Page 5 of 25
t of previous root canal therapy pal regeneration - initial visit124.00124.00Pulpal regeneration - interim medication replacement82.0082.00Pulpal regeneration - completion of treatment82.0082.00Apicoectomy - anterior389.00389.00Apicoectomy - bicuspid premolar (first root)467.00467.00Apicoectomy - molar (first root)487.00487.00Apicoectomy - (each additional root)175.00175.00Periradicular surgery without apicoectomy420.00420.00Bone graft in conjunction with periradicular surgery - per tooth, single site194.00194.00Bone graft in conjunction with periradicular surgery - each additional contiguoustooth in the same surgical site145.00145.00Retrograde filling - per root77.0077.00Guided tissue regeneration, resorbable barrier, per site, in conjunction withperiradicular surgery243.00243.00Root amputation - per root252.00252.00Hemisection (including any root removal), not including root canal .00713.00261.00Bone replacement graft - retained natural tooth - first site in quadrant303.00111.00Bone replacement graft - retained natural tooth - each additional site in quadrant145.00145.00Guided tissue regeneration - resorbable barrier, per site243.00243.00Guided tissue regeneration - non-resorbable barrier, per site (includes membraneremoval)282.00282.00Pedicle soft tissue graft 45.00Apexification/recalcification - initial visit (apical closure/calcific repair of perforations,root resorption, etc.)Apexification/recalcification - interim medication replacement (apical closure/calcificrepair of perforations, root resorption, pulp space disinfection, etc.)Apexification/recalcification - final visit (apical closure/calcific repair of perforations,root resorption, pulp space disinfection, etc.)Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth boundedspaces per quadrantGingivectomy or gingivoplasty - one to three contiguous teeth or tooth boundedspaces per quadrantGingivectomy or gingivoplasty to allow access for restorative procedure, per toothGingival flap procedure, including root planing - four or more contiguous teeth ortooth bounded spaces per quadrantGingival flap procedure, including root planing - one to three contiguous teeth ortooth bounded spaces per quadrantClinical crown lengthening - hard tissueOsseous surgery (including elevation of a full thickness flap and closure) - four ormore contiguous teeth or tooth bounded spaces per quadrantOsseous surgery (including elevation of a full thickness flap and closure) - one tothree contiguous teeth or tooth bounded spaces per quadrantAutogenous connective tissue graft procedure (including donor and recipientsurgical sites) first tooth, implant, or edentulous tooth position in graftMesial/Distal wedge procedure, single tooth (when not performed in conjunctionwith surgical procedures in the same anatomical area)Non‐autogenous connective tissue graft (including recipient site and donor material)first tooth, implant, or edentulous tooth position inCombined connective tissue and double pedicle graft, per toothFree soft tissue graft procedure (including recipient and donor surgical sites) firsttooth, implant, or edentulous tooth position in graftFree soft tissue graft procedure (including recipient and donor surgical sites) eachadditional contiguour tooth, implant, or edentulous tooth position in graftAutogenous connective tissue graft procedure (including donor and recipientsurgical sites) – each additional contiguous tooth, implant or edentulous toothposition in same graft siteUpdated 01/01/18CDT 18Page 6 of 25
genous connective tissue graft procedure (including recipient surgical siteand donor material) – each additional contiguous tooth, implant or edentulous toothposition in same graft site329.00329.00Periodontal scaling and root planing - four or more teeth per quadrant126.00126.00Periodontal scaling and root planing - one to three teeth per riodontal maintenance53.0053.00Complete denture - maxillary601.00220.00Complete denture - mandibular601.00220.00Immediate denture - maxillary628.00230.00Immediate denture - 252.00688.00252.00Maxillary partial denture - flexible base (including any clasps, rests and teeth)655.00240.00Mandibular partial denture - flexible base (including any clasps, rests and teeth)655.00240.00Removable unilateral partial denture - one piece cast metal (including clasps andteeth)166.00166.00Adjust complete denture - maxillary39.0039.00Adjust complete denture - mandibular39.0039.00Adjust partial denture - maxillary39.0039.00Adjust partial denture - mandibular39.0039.00Repair broken complete denture base, mandibular126.00126.00Repair broken complete denture base, maxillary126.00126.00Replace missing or broken teeth - complete denture (each tooth)98.0098.00Repair resin partial denture base, mandibular88.0088.00Repair resin partial denture base, maxillary88.0088.00Repair cast partial framework, mandibular98.0098.00Repair cast partial framework, maxillary98.0098.00Repair or replace broken clasp - per tooth77.0077.00Replace broken teeth - per tooth77.0077.00Add tooth to existing partial denture98.0098.00Add clasp to existing partial denture - per tooth137.00137.00Rebase complete maxillary denture301.00301.00Scaling in presence of generalized moderate or severe gingival inflammation - fullmouth, after oral evaluationScaling in presence of generalized moderate or severe gingival inflammation - fullmouth, after oral evaluationFull mouth debridement to enable comprehensive evaluation and diagnosis on asubsequent visitMaxillary partial denture - resin base (including any conventional clasps, rests andteeth)Mandibular partial denture - resin base (including any conventional clasps, rests andteeth)Maxillary partial denture - cast metal framework with resin denture bases (includingany conventional clasps, rests and teeth)Mandibular partial denture - cast metal framework with resin denture bases(including any conventional clasps, rests and teeth)Immediate maxillary partial denture – resin base (including any conventional clasps,rests and teeth)Immediate mandibular partial denture – resin base (including any conventionalclasps, rests and teeth)Immediate maxillary partial denture – cast metal framework with resin denturebases (including any conventional clasps, rests and teeth)Immediate mandibular partial denture – cast metal framework with resin denturebases (including any conventional clasps, rests and teeth)Updated 01/01/18CDT 18Page 7 of 25
e complete mandibular denture301.00301.00Rebase maxillary partial denture282.00282.00Rebase mandibular partial denture282.00282.00Reline complete maxillary denture (chairside)145.00145.00Reline complete mandibular denture (chairside)145.00145.00Reline maxillary partial denture (chairside)117.00117.00Reline mandibular partial denture (chairside)117.00117.00Reline complete maxillary denture (laboratory)252.00252.00Reline complete mandibular denture (laboratory)252.00252.00Reline maxillary partial denture (laboratory)214.00214.00Reline mandibular partial denture (laboratory)214.00214.00Interim partial denture (maxillary)205.0075.00Interim partial denture (mandibular)205.0075.00Tissue conditioning, maxillary77.0077.00Tissue conditioning, mandibular77.0077.00Surgical placement of implant body: endosteal implant985.00225.00Second stage implant surgery385.00110.00Surgical placement of mini implant788.00225.00Surgical placement: eposteal implant1,173.00335.00Surgical placement: transosteal implant1,466.00335.00Connecting bar - implant supported or abutment supported910.00260.00Prefabricated abutment - includes modification and placement420.0096.00Custom fabricated abutment - includes placement579.00133.00Abutment supported porcelain/ceramic crown810.00185.00Abutment supported porcelain fused to metal crown (high noble metal)829.00180.001,143.00160.00Abutment supported porcelain fused to metal crown (noble metal)659.00170.00Abutment supported cast metal crown (high noble metal)776.00170.00Abutment supported cast metal crown (predominantly base metal)508.00145.00Abutment supported cast metal crown (noble metal)700.00160.00Implant supported porcelain/ceramic crown875.00185.00Implant supported porcelain fused to metal crown (titanium, titanium alloy, highnoble metal)837.00180.00Implant supported metal crown (titanium, titanium alloy, high noble metal)837.00170.00Abutment supported retainer for porcelain/ceramic FPD810.00185.00Abutment supported retainer for porcelain fused to metal FPD (high noble metal)859.00180.00Abutment supported retainer for porcelain fused to metal FPD (predominantly basemetal)560.00160.00Abutment supported retainer for porcelain fused to metal FPD (noble metal)659.00170.00Abutment supported retainer for cast metal FPD (high noble metal)818.00170.00Abutment supported retainer for cast metal FPD (predominantly base metal)508.00145.00Abutment supported porcelain fused to metal crown (predominantly base metal)Updated 01/01/18CDT 18Page 8 of 25
ent supported retainer for cast metal FPD (noble metal)560.00160.00Implant supported retainer for ceramic FPD648.00185.00859.00180.00595.00170.00Repair implant supported prosthesis, by report252.0072.00Recement or re-bond implant/abutment supported crown98.0028.00Recement or re-bond implant/abutment supported fixed partial denture137.0039.00Abutment supported crown (titanium)818.00170.00Repair implant abutment, by report252.0072.00Implant removal, by report322.0092.00Bone graft at time of implant placement389.00111.00Implant/abutment supported removable denture for edentulous arch - maxillary1,046.00231.00Implant/abutment supported removable denture for edentulous arch - plant/abutment supported fixed denture for edentulous arch - maxillary770.00220.00Implant/abutment supported fixed denture for edentulous arch - mandibular770.00220.00Implant/abutment supported fixed denture for partially edentulous arch - maxillary840.00240.00Implant/abutment supported fixed denture for partially edentulous arch - mandibular840.00240.00Radiographic/surgical implant index, by report256.0073.00Abutment supported retainer crown for FPD (titanium)595.00170.00Pontic - cast high noble metal478.00175.00Pontic - cast predominantly base metal396.00145.00Pontic - cast noble metal437.00160.00Pontic - titanium491.00180.00Pontic - porcelain fused to high noble metal491.00180.00Pontic - porcelain fused to predominantly base metal423.00155.00Pontic - porcelain fused to noble metal464.00170.00Pontic - porcelain/ceramic505.00185.00Pontic - resin with high noble metal437.00160.00Pontic - resin with predominantly base metal382.00140.00Pontic - resin with noble metal423.00155.00Retainer - cast metal for resin bonded fixed prosthesis177.0065.00Retainer - porcelain/ceramic for resin bonded fixed prosthesis177.0065.00Resin retainer - for resin bonded fixed prothesis90.0033.00Retainer crown - indirect resin based composite341.00125.00Retainer crown - resin with high noble metal437.00160.00Retainer crown - resin with predominantly base metal396.00145.00Retainer crown - resin with noble metal423.00155.00Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy,or high noble metal)Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noblemetal)Implant/abutment supported removable denture for partially edentulous arch maxillaryImplant/abutment supported removable denture for partially edentulous arch mandibularUpdated 01/01/18CDT 18Page 9 of 25
ner crown - porcelain/ceramic505.00185.00Retainer crown - porcelain fused to high noble metal491.00180.00Retainer crown - porcelain fused to predominantly base metal437.00160.00Retainer crown - porcelain fused to noble metal464.00170.00Retainer crown - 3/4 cast high noble metal437.00160.00Retainer crown - 3/4 cast predominantly base metal369.00135.00Retainer crown - 3/4 cast noble metal369.00135.00Retainer crown - 3/4 porcelain/ceramic437.00160.00Retainer crown - full cast high noble metal464.00170.00Retainer crown - full cast predominantly base metal396.00145.00Retainer crown - full cast noble metal437.00160.00Retainer crown - titanium464.00170.00Re-cement or re-bond fixed partial denture68.0068.00Fixed partial denture repair necessitated by restorative material failure126.00126.00Extraction, coronal remnants - deciduous primary tooth68.0068.00Extraction, erupted tooth or exposed root (elevation and/or forceps removal)68.0068.00Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, andincluding elevation of mucoperiosteal flap if indicated137.00137.00Removal of impacted tooth - soft tissue (STI)186.00186.00Removal of impacted tooth - partially bony (PBI)243.00243.00Removal of impacted tooth - completely bony (FBI)301.00301.00Removal of impacted tooth - completely bony, with unusual surgical complications(FBID)331.00331.00Removal of residual tooth roots (cutting procedure)145.00145.00Oroantral fistula closure331.00331.00Exposure of an unerupted tooth340.00340.00Incisional Biopsy of oral tissue - hard (bone, tooth)145.00145.00Incisional Biopsy of oral tissue - soft145.00145.00Brush Biopsy - transepithelial sample 00165.00128.0047.00Excision of benign lesion up to 1.25 cm186.00186.00Excision of benign lesion greater than 1.25 cm278.00278.00Excision of benign lesion, complicated306.00306.00Excision of malignant lesion up to 1.25 cm186.00186.00Excision of malignant lesion greater than 1.25 cm278.00278.00Excision of malignant lesion, complicated306.00306.00Excision of malignant tumor - lesion diameter up to 1.25 cm233.00233.00Excision of malignant tumor - lesion diameter over 1.25 cm243.00243.00Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces,per quadrantAlveoloplasty in conjunction with extractions - one to three teeth or tooth spaces,per quadrantAlveoloplasty not in conjunction with extractions - four or more teeth or toothspaces, per quadrantAlveoloplasty not in conjunction with extractions - one to three teeth or toothspaces, per quadrantUpdated 01/01/18CDT 18Page 10 of 25
D8070D8080D8090D8210D8660D8670D8680Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm224.00224.00Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25cm233.00233.00Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm194.00194.00Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than1.25 cm418.00418.00Removal of lateral exostosis (maxilla or mandible)292.00292.00Incision and drainage of abscess - intraoral soft tissue98.0098.00Incision and drainage of abscess - intraoral soft tissue - complicated (includeddrainage of multiple fascial spaces)109.00109.00Incision and drainage of abscess - extraoral soft tissue117.00117.00Incision and drainage of abscess - extraoral soft tissue - complicated (includeddrainage of multiple fascial spaces)128.00128.00Bone replacement graft for ridge preservation - per site389.00111.00Frenulectomy - also known as frenectomy or frenotomy - separate procedure notincidental to another sion of hyperplastic tissue - per arch186.00186.00Excision of pericoronal gingiva98.0098.00Limited orthodontic treatment of the primary dentition - Considered under age 3.003,526.00653.00Removable appliance therapy88.0022.00Pre-orthodontic treatment examination to monitor growth and development Considered under age 19340.0063.00Periodic orthodontic treatment visit - Considered under age 1976.0014.00572.00106.0022.004.00Re-cement or re-bonding of fixed retainers - Considered under age 19156.0039.00Palliative (emergency) treatment of dental pain - minor procedure47.0047.00Deep sedation/general anesthesia - first 30 minutes103.00103.00Deep sedation/general anesthesia - each additional 15 minutes103.00103.00Deep sedation/general anesthesia – first 15 minutes103.00103.00Deep sedation/general anesthesia – each subsequent 15 minute increment138.00103.00Intravenous moderate (conscious) sedati
Crown - resin with noble metal 396.00 145.00 D2740 Crown - porcelain/ceramic substrate 686.00 185.00 D2750 Crown - porcelain fused to high noble metal 614.00 180.00 D2751 Crown - porcelain fused to predominantly base metal 546.00 160.00 D2752 Crown - porcelain fused to noble metal 617.00 170.00 D2780 Crown - 3/4 cast high noble metal 595.00 165 .
