| ADA Code | ADA Description | HNA LEVEL 2 FEES |
|---|---|---|
| PREVENTATIVE | ||
| D0120 | Periodic oral evaluation - established patient | 50 |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver | 50 |
| D0150 | Comprehensive oral evaluation - new or established patient | 50 |
| D0160 | Detailed and extensive oral evaluation - problem focused | 50 |
| D0170 | Re-evaluation - limited, problem focused | 50 |
| D0180 | Comprehensive periodontal evaluation - new or established patient | 50 |
| D0425 | Caries susceptibility to oral diseases | 50 |
| D1110 | Prophylaxis - adult | 50 |
| D1120 | Prophylaxis - child | 50 |
| D1203 | Topical application of fluoride - child | 50 |
| D1204 | Topical application of fluoride - adult | 50 |
| D1206 | Topical fluoride varnish; therapeutic application for moderate to high caries risk patients | 50 |
| D1310 | Nutritional counseling for control of dental disease | 50 |
| D1320 | Tobacco counseling for control and prevention of oral disease | 50 |
| D1330 | Oral hygiene instructions | 50 |
| D4910 | Periodontal maintenance procedures following active therapy | 50 |
| D9430 | Office visit for observation (during regularly scheduled hours) - no other services performed | 50 |
| D9910 | Application of desensitizing medicament | 50 |
| X-RAYS | ||
| D0210 | Intraoral - complete series (including bite wings) | 35 |
| D0220 | Intraoral - periapical first film | 35 |
| D0230 | Intraoral - periapical each additional film | 35 |
| D0240 | Intraoral - occlusal film | 35 |
| D0250 | Extraoral - first film | 35 |
| D0260 | Extraoral - each additional film | 35 |
| D0270 | Bitewing - single film | 35 |
| D0272 | Bitewings - two films | 35 |
| D0273 | Bitewings - three films | 35 |
| D0274 | Bitewings - four films | 35 |
| D0277 | Vertical bitewings - 7 to 8 films | 35 |
| D0330 | Panoramic film | 35 |
| D0340 | Cephalometric film | 35 |
| RESORATIVE | ||
| D0140 | Limited oral evaluation - problem focused | 35 |
| D0290 | Posterior - anterior or lateral skull and facial bone survey film | 90 |
| D0310 | Sialography | 225 |
| D0415 | Collection of microorganisms for culture and sensitivity-Bacteriologic Studies for Det. | |
| D0417 | Collection and preparation of saliva sample for laboratory diagnostic testing | |
| D0418 | Analysis of saliva sample | |
| D0431 | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities | |
| D0460 | Pulp vitality tests | |
| D0470 | Diagnostic casts | |
| D2140 | Amalgam - one surface, primary | 65 |
| permanent | 90 | |
| D2150 | Amalgam - two surfaces, primary | 75 |
| permanent | 95 | |
| D2160 | Amalgam - three surfaces, primary | 75 |
| permanent | 100 | |
| D2161 | Amalgam - four or more surfaces, primary | 90 |
| permanent | 115 | |
| D2330 | Resin-based composite - one surface, anterior | 85 |
| D2331 | Resin-based composite - two surfaces, anterior | 100 |
| D2332 | Resin-based composite - three surfaces, anterior | 120 |
| D2335 | Resin-based composite - four or more surfaces or involving incisal angle (anterior) | 145 |
| D2390 | Resin-based composite crown, anterior | 145 |
| D2391 | Resin-based composite - one surface, posterior, Primary | 75 |
| Permanent | 85 | |
| D2392 | Resin-based composite - two surfaces, posterior, Primary | 95 |
| Permanent | 100 | |
| D2393 | Resin-based composite - three surfaces, posterior, Primary | 115 |
| Permanent | 120 | |
| D2394 | Resin-based composite - four or more surfaces, posterior, Primary | 115 |
| Permanent | 120 | |
| D2410 | Gold foil - one surface | 300 |
| D2420 | Gold foil - two surfaces | 330 |
| PAIN MANAGEMENT | ||
| D9110 | Palliative (emergency) treatment dental pain - minor procedure | 40 |
| D9220 | Deep sedation/general anesthesia - first 30 minutes | 105 |
| D9221 | Deep sedation/general anesthesia - each additional 1 5 minutes | 105 |
| D9230 | Inhalation of nitrous oxide/analgesia, anxiolysis | 105 |
| D9241 | Intravenous conscious sedation/analgesia - first 30 minutes | 165 |
| D9310 | Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician | 40 |
| D9410 | House/extended care facility call | 40 |
| D9420 | Hospital or ambulatory surgical center call | 40 |
| D9440 | Office visit - after regular office hours | 40 |
| D9450 | Case presentation, detailed and extensive treatment planning | 40 |
| Other Preventative | ||
| D1351 | Sealant - per tooth | 25 |
| D1510 | Space maintainer - fixed - unilateral | 110 |
| D1515 | Space maintainer - fixed - bilateral | 145 |
| D1520 | Space maintainer - removable - unilateral | 115 |
| D1525 | Space maintainer - removable - bilateral | 145 |
| D1550 | Re-cementation of space maintainer | 55 |
| D1555 | Removal of fixed space maintainer | 115 |
| ORAL SURGERY, GUM TREATMENTS, AND PROSTHETIC REPAIR | ||
| D4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quad | 190 |
| D4211 | Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quad | 60 |
| D4230 | Anatomical Crown Exposure (four or more contiguous teeth per quad) | 190 |
| D4231 | Anatomical Crown Exposure (one to three teeth per quad) | 60 |
| D4240 | Ging flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quad | 330 |
| D4241 | Gingival flap procedure, including root planning - one to three contiguous teeth or tooth bounded spaces per quad | 330 |
| D4249 | Clinical crown lengthening - hard tissue | 360 |
| D4260 | Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quad | 360 |
| D4261 | Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quad | 360 |
| D4263 | Bone replacement graft - first site in quad | 390 |
| D4264 | Bone replacement graft - each additional site in quad | 300 |
| D4270 | Pedicle soft tissue graft procedure | 390 |
| D4271 | Free soft tissue graft procedure (including donor site surgery) | 390 |
| D4273 | Sub epithelial connective tissue graft .procedures, per tooth | 450 |
| D4275 | Soft tissue allograft | 390 |
| D4320 | Provisional splinting - intracoronal | 215 |
| D4321 | Provisional splinting - extracoronal | 180 |
| D4341 | Periodontal scaling and root planning - four or more teeth per quad | 95 |
| D4342 | Periodontal scaling and root planning - one to three teeth per quad | 95 |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | 75 |
| D5410 | Adjust complete denture - maxillary | 35 |
| D5411 | Adjust complete denture - mandibular | 35 |
| D5421 | Adjust partial denture - maxillary | 35 |
| D5422 | Adjust partial denture - mandibular | 35 |
| D5510 | Repair broken complete denture base | 60 |
| D5520 | Replace missing or broken teeth - complete denture (each tooth) | 55 |
| D5610 | Repair resin denture base | 60 |
| D5620 | Repair cast framework | 90 |
| D5630 | Repair or replace broken clasp | 80 |
| D5640 | Replace broken teeth - per tooth | 55 |
| D5650 | Add tooth to existing partial denture | 65 |
| D5660 | Add clasp to existing partial denture | 90 |
| D5710 | Rebase complete maxillary denture | 190 |
| D5711 | Rebase complete mandibular denture | 240 |
| D5720 | Rebase maxillary partial denture | 240 |
| D5721 | Rebase mandibular partial denture | 240 |
| D5730 | Reline complete maxillary denture (chairside) | 115 |
| D5731 | Reline complete mandibular denture (chairside) | 115 |
| D5740 | Reline maxillary partial denture (chairside) | 130 |
| D5741 | Reline mandibular partial denture (chairside) | 130 |
| D5620 | Reline complete maxillary denture (lab) | 155 |
| D5621 | Reline complete mandibular denture (lab) | 155 |
| D5760 | Reline maxillary partial denture (lab) | 190 |
| D5761 | Reline mandibular partial denture (lab) | 190 |
| D5850 | Tissue conditioning, maxillary | 60 |
| D5851 | Tissue conditioning, mandibular | 60 |
| D6090 | Repair implant supported prosthesis | 155 |
| D6091 | Replacement of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment | 155 |
| D6092 | Recement implant/abutment supported crown | 155 |
| D6093 | Recement implant/abutment supported fixed partial denture | 0 |
| D6095 | Repair implant abutment | 155 |
| D6100 | Implant removal | 50 |
| D6930 | Recement fixed partial denture | 50 |
| D7111 | Extraction, coronal remnants, deciduous tooth | 70 |
| D7140 | Extraction, erupted tooth or exposed root | 60 |
| D7210 | Surgical removal of erupted tooth | 110 |
| D7220 | Removal of impacted tooth - soft tissue | 145 |
| D7230 | Removal of impacted tooth - partial bony | 170 |
| D7240 | Removal of impacted tooth - completely bony | 190 |
| D7241 | Removal of impacted tooth - completely bony, with unusual surgical complications | 205 |
| D7250 | Surgical removal residual tooth roots (cutting procedure) | 100 |
| D7260 | Oroantral fistula closure | 270 |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | 270 |
| D7280 | Surgical access of an unerupted tooth | 300 |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | 95 |
| D7283 | Placement of device to facilitate eruption of impacted tooth | 95 |
| D7285 | Biopsy of oral tissue - hard (bone, tooth) | 510 |
| D7286 | Biopsy of oral tissue - soft | 215 |
| D7310 | Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quad | 90 |
| D7311 | Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quad | 90 |
| D7320 | Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quad | 120 |
| D7321 | Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quad | 120 |
| D7340 | Vestibuloplasty - uncomplicated | 1170 |
| D7350 | Vestibuloplasty - complicated | 1110 |
| D7410 | Excision of benign lesion up to 1.25 cm | 780 |
| D7411 | Excision of benign lesion greater than 1.25 cm | 780 |
| D7412 | Excision of benign lesion, complicated | 780 |
| D7413 | Excision of malignant lesion up to 1.25 cm | 960 |
| D7414 | Excision of malignant lesion greater than 1.25 cm | 960 |
| D7415 | Excision of malignant lesion, complicated | 960 |
| D7440 | Excision of malignant tumor - lesion diameter up to 1.25 cm | 960 |
| D7441 | Excision of malignant tumor - lesion diameter greater than 1.25 cm | 960 |
| D7450 | Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm | 780 |
| D7451 | Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1 .25 cm | 780 |
| D7460 | Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1 .25 cm | 780 |
| D7461 | Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm | 780 |
| D7471 | Removal of lateral exostosis (maxilla or mandible) | 540 |
| D7472 | Removal of torus palatinus | 540 |
| D7473 | Removal of torus mandibularis | 540 |
| D7485 | Surgical reduction of osseous tuberosity | 660 |
| D7510 | Incision and drainage of abscess - intraoral soft tissue | 145 |
| D7511 | Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | 675 |
| D7520 | Incision and drainage of abscess - extraoral soft tissue | 675 |
| D7521 | Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | 675 |
| D7530 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | 240 |
| D7540 | Removal of reaction producing foreign bodies, musculoskeletal system | 270 |
| D7550 | Partial ostectomy/sequestrectomy for removal of non-vital bone | 170 |
| D7560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | 1110 |
| D7610 | Maxilla - open reduction (simple) | 1110 |
| D7620 | Maxilla - closed reduction (simple) | 1110 |
| D7630 | Mandible - open reduction (simple) | 90 |
| D7640 | Mandible - closed reduction (simple) | 120 |
| D7650 | Malar and/or zygomatic arch - open reduction (simple) | 1110 |
| D7660 | Malar and/or zygomatic arch - closed reduction (simple) | 780 |
| D7670 | Alveolus - closed reduction, may include stabilization of teeth (simple) | 1020 |
| D7671 | Alveolus - open reduction, may include stabilization of teeth (simple) | 540 |
| D7710 | Maxilla - open reduction (compound) , | 1110 |
| D7720 | Maxilla - closed reduction (compound) | 1110 |
| D7730 | Mandible - open reduction (compound) | 120 |
| D7740 | Mandible - closed reduction (compound) | 120 |
| D7750 | Malar and/or zygomatic arch - open reduction (compound) | 480 |
| D7760 | Malar and/or zygomatic arch - closed reduction (compound) | 480 |
| D7770 | Alveolus - open reduction stabilization of teeth (compound) | 540 |
| D7771 | Alveolus - closed reduction stabilization of teeth (compound) | 1020 |
| D7960 | Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another | 120 |
| D7963 | Frenuloplasty | 120 |
| D7970 | Excision of hyperplastic tissue - per arch | 120 |
| D7971 | Excision of pericoronal gingiva | 100 |
| D9120 | Fixed partial denture sectioning | 50 |
| CROWNS AND MAJOR SERVICES | ||
| D2510 | Inlay - metallic - one surface | 315 |
| D2520 | Inlay - metallic - two surfaces | 350 |
| D2530 | Inlay - metallic - three or more surfaces | 560 |
| D2542 | Onlay - metallic - two surfaces | 420 |
| D2543 | Onlay - metallic - three surfaces | 455 |
| D2544 | Onlay - metallic - four or more surfaces | 490 |
| D2610 | Inlay - porcelain/ceramic - one surface | 340 |
| D2620 | Inlay - porcelain/ceramic - two surfaces | 385 |
| D2630 | Inlay - porcelain/ceramic - three or more surfaces | 595 |
| D2642 | Onlay - porcelain/ceramic - two surfaces | 455 |
| D2643 | Onlay - porcelain/ceramic - three surfaces | 490 |
| D2644 | Onlay - porcelain/ceramic - four or more surfaces | 525 |
| D2650 | Inlay - resin-based composite - one surface | 315 |
| D2651 | Inlay - resin-based composite - two surfaces | 350 |
| D2652 | Inlay - resin-based composite - three or more surfaces | 455 |
| D2662 | Onlay - resin-based composite - two surfaces | 385 |
| D2663 | Onlay - resin-based composite - three surfaces | 455 |
| D2664 | Onlay - resin-based composite - four or more surfaces | 455 |
| D2710 | Crown - resin-based composite (indirect) | 265 |
| D2712 | Crown - 3/4 resin-based composite (indirect) | 265 |
| D2720 | Crown - resin with high noble metal | 810 |
| D2721 | Crown - resin with predominantly base metal | 810 |
| D2722 | Crown - resin with noble metal | 810 |
| D2740 | Crown - porcelain/ceramic substrate | 810 |
| D2750 | Crown - porcelain fused to high noble metal | 810 |
| D2751 | Crown - porcelain fused to predominantly base metal | 810 |
| D2752 | Crown - porcelain fused to noble metal | 810 |
| D2780 | Crown - 3/4 cast high noble metal | 810 |
| D2781 | Crown - 3/4 cast predominantly base metal | 810 |
| D2782 | Crown - 3/4 cast noble metal | 810 |
| D2783 | Crown - 3/4 porcelain/ceramic | 810 |
| D2790 | Crown - full cast high noble metal | 810 |
| D2791 | Crown - full cast predominantly base metal | 810 |
| D2792 | Crown - full cast noble metal | 810 |
| D2794 | Crown - titanium | 810 |
| D2910 | Recement inlay, onlay, or partial coverage restoration | 55 |
| D2915 | Recement cast or prefabricated post and core | 55 |
| D2920 | Recement crown | 55 |
| D2930 | Prefabricated stainless steel crown - primary tooth | 110 |
| D2931 | Prefabricated stainless steel crown - permanent tooth | 120 |
| D2932 | Prefabricated resin crown | 180 |
| D2933 | Prefabricated stainless steel crown with resin window | 185 |
| D2934 | Prefabricated esthetic coated stainless steel crown - primary tooth | 110 |
| D2940 | Protective restoration | 50 |
| D2950 | Crown buildup - including any pins | 110 |
| D2951 | Pin retention - per tooth in addition to restoration | 35 |
| D2952 | Post and core in addition to crown, indirectly fabricated | 155 |
| D2954 | Prefabricated post & core in addition to crown | 180 |
| D2955 | Post removal (not in conjunction with endodontic therapy) | 125 |
| D2980 | Crown repair | 265 |
| D3110 | Pulp cap - direct (excluding final restoration) | 30 |
| D3120 | Pulp cap - indirect (excluding final restoration) | 30 |
| D3220 | Therapeutic pulpotomy (excluding final restoration) | 70 |
| D3222 | Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development | 70 |
| D3230 | Pulpal therapy - anterior, primary tooth (excluding final restoration) | 70 |
| D3240 | Pulpal therapy - posterior, primary tooth (excluding final restoration) | 70 |
| D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | 335 |
| D3320 | Endodontic therapy, bicuspid tooth (excluding final restoration) | 385 |
| D3330 | Endodontic therapy, molar (excluding final restoration) | 525 |
| D3346 | Retreatment of previous root canal therapy- anterior | 280 |
| D3347 | Retreatment of previous root canal therapy- bicuspid | 350 |
| D3348 | Retreatment of previous root canal therapy- molar | 455 |
| D3351 | Apexification/recalcification/pulpal regeneration - initial visit ' | 225 |
| D3352 | Apexification/recalcification/pulpal regeneration - interim medication replacement | 55 |
| D3353 | Apexification/recalcification - final visit | 110 |
| D3410 | Apicoectomy/periradicular surgery - anterior | 235 |
| D3421 | Apicoectomy/periradicular surgery - bicuspid (first root) | 455 |
| D3425 | Apicoectomy/periradicular surgery - molar (first root) | 560 |
| D3426 | Apicoectomy/periradicular surgery (each additional root) | 180 |
| D3430 | Retrograde filling - per root | 130 |
| D3450 | Root amputation - per root | 265 |
| D3920 | Hemisection - (including root removal); not including root canal therapy | 210 |
| D3950 | Canal preparation and fitting of preformed dowel or post | 90 |
| MAJOR PROSTHETIC SERVICES | ||
| D5110 | Complete denture - maxillary | 735 |
| D5120 | Complete denture - mandibular | 735 |
| D5130 | Immediate denture - maxillary | 735 |
| D5140 | Immediate denture - mandibular | 735 |
| D5211 | Maxillary partial denture - resin base (including any conventional clasps, rests, and teeth) | 525 |
| D5212 | Mandibular partial denture - resin base (including any conventional clasps, rests, and teeth) | 525 |
| D5213 | Max partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) | 770 |
| D5214 | Mand partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) | 770 |
| D5225 | Maxillary partial denture - flexible base (including clasps, rests, and teeth) | 770 |
| D5226 | Mandibular partial denture - flexible base (including clasps, rests, and teeth) | 770 |
| D5281 | Removable unilateral partial denture - one piece cast metal (including clasps and teeth) | 525 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | 60 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | 60 |
| D5810 | Interim complete denture (maxillary) | 350 |
| D5811 | Interim complete denture (mandibular) | 420 |
| D5820 | Interim partial denture (maxillary) | 280 |
| D5821 | Interim partial denture (mandibular) | 315 |
| D6010 | Surgical placement of implant body: endosteal implant | 910 |
| D6012 | Surgical Placement of Interim Implant Body for Transitional Prosthetics: Endosteal Implant | 910 |
| D6040 | Surgical placement: eposteal implant | 910 |
| D6050 | Surgical placement : transosteal implant | 910 |
| D6056 | Prefabricated abutment - includes placement | 910 |
| D6057 | Custom abutment - includes placement | 910 |
| D6058 | Abutment supported porcelain/ceramic crown | 525 |
| D6059 | Abutment supported porcelain fused to metal crown (high noble metal) | 525 |
| D6060 | Abutment supported porcelain fused to metal crown (predominantly base metal) | 525 |
| D6061 | Abutment supported porcelain fused to metal crown (noble metal) | 525 |
| D6062 | Abutment supported cast metal crown (high noble metal) | 525 |
| D6063 | Abutment supported cast metal crown (predominantly base metal) | 525 |
| D6064 | Abutment supported cast metal crown (noble metal) | 525 |
| D6065 | Implant supported porcelain/ceramic crown | 525 |
| D6066 | Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | 525 |
| D6067 | Implant supported metal crown (titanium, titanium alloy, high noble metal) | 525 |
| D6068 | Abutment supported retainer for porcelain/ceramic FPD | 525 |
| D6069 | Abutment supported retainer for porcelain fused to metal FPD (high noble metal) | 525 |
| D6070 | Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) | 525 |
| D6071 | Abutment supported retainer for porcelain fused to metal FPD (noble metal) | 525 |
| D6072 | Abutment supported retainer for cast metal FPD (high noble metal) | 525 |
| D6073 | Abutment supported retainer for cast meta! FPD (predominantly base metal) | 525 |
| D6074 | Abutment supported retainer for cast metal FPD (noble metal) | 525 |
| D6075 | Implant supported retainer for ceramic FPD | 525 |
| D6076 | Implant supported retainer for porcelain fused to metal FPD (ti, ti alloy, high noble metal) | 525 |
| D6077 | Implant supported retainer for cast metal FPD (titanium, titanium alloy, high noble metal) | 525 |
| D6078 | Implant/abutment supported fixed denture for completely edentulous arch | 525 |
| D6079 | Implant/abutment supported fixed denture for partially edentulous arch | 525 |
| D6080 | Implant maintenance procedures | 315 |
| D6094 | Abutment supported crown (titanium) | 525 |
| D6194 | Abutment supported retainer crown for FPD (titanium) | 525 |
| D6205 | Pontic - indirect resin based composite | 525 |
| D6210 | Pontic - cast high noble metal | 525 |
| D6211 | Pontic - cast predominantly base metal | 525 |
| D6212 | Pontic - cast noble metal | 525 |
| D6214 | Pontic - titanium | 525 |
| D6240 | Pontic - porcelain fused to high noble metal | 525 |
| D6241 | Pontic - porcelain fused to predominantly base metal | 525 |
| D6242 | Pontic - porcelain fused to noble metal | 525 |
| D6245 | Pontic - porcelain/ceramic | 525 |
| D6250 | Pontic - resin with high noble metal | 525 |
| D6251 | Pontic - resin with predominantly base metal | 525 |
| D6252 | Pontic - resin with noble metal | 525 |
| D6253 | Provisional pontic | 525 |
| D6545 | Cast metal retainer for resin bonded fixed prosthesis | 235 |
| D6548 | Porcelain/ceramic retainer for resin bonded fixed prosthesis | 235 |
| D6600 | Inlay - porcelain/ceramic, two surfaces | 385 |
| D6601 | Inlay - porcelain/ceramic, three or more surfaces | 595 |
| D6602 | Inlay - cast high noble metal, two surfaces | 525 |
| D6603 | Inlay - cast high noble metal, three or more surfaces | 560 |
| D6604 | Inlay - cast predominantly base metal, two surfaces | 525 |
| D6605 | Inlay - cast predominantly base metal, three or more surfaces | 560 |
| D6606 | Inlay - cast noble metal, two surfaces | 525 |
| D6607 | Inlay - cast noble metal, three or more surfaces | 560 |
| D6608 | Onlay - porcelain/ceramic, two surfaces | 455 |
| D6609 | Onlay - porcelain/ceramic, three or more surfaces | 490 |
| D6610 | Onlay - cast high noble metal, two surfaces | 560 |
| D6611 | Onlay - cash high noble metal, three or more surfaces | 595 |
| D6612 | Onlay - cast predominantly base metal, two surfaces | 540 |
| D66I3 | Onlay - cast predominantly base metal, three or more surfaces | 595 |
| D6614 | Onlay - cast noble metal, two surfaces | 540 |
| D6615 | Onlay - cast noble metal, three or more surfaces | 595 |
| D6624 | Inlay - titanium | 540 |
| D6634 | Onlay - titanium | 595 |
| D6710 | Crown - indirect resin based composite | 525 |
| D6720 | Crown - resin with high noble metal | 525 |
| D6721 | Crown - resin with predominantly base, metal | 525 |
| D6722 | Crown - resin with noble metal | 525 |
| D6740 | Crown - porcelain/ceramic | 525 |
| D6750 | Crown - porcelain fused to high noble metal | 525 |
| D6751 | Crown - porcelain fused to predominantly base metal | 525 |
| D6752 | Crown - porcelain fused to noble metal | 525 |
| D6780 | Crown - 3/4 cast high noble metal | 525 |
| D6781 | Crown - 3/4 cast predominantly base metal | 525 |
| D6782 | Crown - 3/4 cast noble metal | 525 |
| D6783 | Crown - 3/4 porcelain/ceramic | 525 |
| D6790 | Crown - full cast high noble metal | 525 |
| D6791 | Crown - full cast predominantly base metal | 525 |
| D6792 | Crown - full cast noble metal | 525 |
| D6793 | Provisional retainer crown | 525 |
| D6794 | Crown - titanium | 525 |
| D6970 | Post and core in addition to fixed partial denture retainer, indirectly fabricated | 225 |
| D6972 | Prefabricated post and core in addition to fixed partial denture retainer | 180 |
| D6973 | Core build up for retainer, including any pins | 140 |
| D6975 | Coping - metal | 420 |
| ADA Code | ADA Description | HNA LEVEL 2 FEES |
|---|---|---|
| PREVENTATIVE | ||
| D0120 | Periodic oral evaluation – established patient | 50 |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver | 50 |
| D0150 | Comprehensive oral evaluation – new or established patient | 50 |
| D0160 | Detailed and extensive oral evaluation – problem focused | 50 |
| D0170 | Re-evaluation – limited, problem focused | 50 |
| D0180 | Comprehensive periodontal evaluation – new or established patient | 50 |
| D0425 | Caries susceptibility to oral diseases | 50 |
| D1110 | Prophylaxis – adult | 50 |
| D1120 | Prophylaxis – child | 50 |
| D1203 | Topical application of fluoride – child | 50 |
| D1204 | Topical application of fluoride – adult | 50 |
| D1206 | Topical fluoride varnish; therapeutic application for moderate to high caries risk patients | 50 |
| D1310 | Nutritional counseling for control of dental disease | 50 |
| D1320 | Tobacco counseling for control and prevention of oral disease | 50 |
| D1330 | Oral hygiene instructions | 50 |
| D4910 | Periodontal maintenance procedures following active therapy | 50 |
| D9430 | Office Visit for Oberservation (during regularly scheduled hours, no other services performed) | 50 |
| D9910 | Application of desensitizing medicament | 50 |
| X-RAYS | ||
| D0210 | Intraoral – complete series (including bite wings) | 35 |
| D0220 | Intraoral – periapical first film | 35 |
| D0230 | Intraoral – periapical each additional film | 35 |
| D0240 | Intraoral – occlusal film | 35 |
| D0250 | Extraoral – first film | 35 |
| D0260 | Extraoral – each additional film | 35 |
| D0270 | Bitewing – single film | 35 |
| D0272 | Bitewings – two films | 35 |
| D0273 | Bitewings – three films | 35 |
| D0274 | Bitewings – four films | 35 |
| D0277 | Vertical bitewings – 7 to 8 films | 35 |
| D0330 | Panoramic film | 35 |
| D0340 | Cephalometric film | 35 |
| OTHER PREVENTATIVE | ||
| D1351 | Sealant(per tooth) | 20 |
| D1510 | Space Maintainer (fixed, unilateral) | 95 |
| D1515 | Space Maintainer (fixed, bilateral) | 120 |
| D1520 | Space Maintainer (removable, unilateral) | 95 |
| D1525 | Space Maintainer (removable, bilateral) | 120 |
| D1550 | Recementation of Space Maintainer | 45 |
| D1555 | Removal of Fixed Retainer Space Maintainer | 95 |
| OTHER DIAGNOSTICS | ||
| D0140 | Limited Oral Evaluation | 30 |
| D0290 | Posterior-Anterior or Lateral Skull and Facial Bone Survey Film | 75 |
| D0310 | Sialography | 190 |
| D0415 | Bacteriologic Studies for determination of Pathologic Agents | 15 |
| D0416 | Viral Culture | 15 |
| D0417 | Collection and Preparation of Saliva for Lab Diagnostic Testing | 15 |
| D0418 | Analysis of Saiva Sample | 15 |
| D0421 | Genetic Test for Susseptability to Oral Diseases | 15 |
| D0431 | Premalignant Lesions, Not to include Cytology or Biology | 15 |
| D0460 | Pulp Vitality Tests | 15 |
| D0470 | Diagnostic Casts | 30 |
| FILLINGS AND BASIC SERVICES | ||
| D2140 | Amalgam – one surface, primary | 55 |
| D2150 | Amalgam – two surfaces, primary | 65 |
| D2160 | Amalgam – three surfaces, primary | 65 |
| D2161 | Amalgam – four or more surfaces, primary | 75 |
| D2330 | Resin-based composite – one surface, anterior | 70 |
| D2331 | Resin-based composite – two surfaces, anterior | 85 |
| D2332 | Resin-based composite – three surfaces, anterior | 100 |
| D2335 | Resin-based composite – four or more surfaces or involving incisal angle (anterior) | 120 |
| D2390 | Resin-based composite crown, anterior | 120 |
| D2391 | Resin-based composite – one surface, posterior, Primary | 65 |
| D2392 | Resin-based composite – two surfaces, posterior, Primary | 80 |
| D2393 | Resin-based composite – three surfaces, posterior, Primary | 95 |
| D2394 | Resin-based composite – four or more surfaces, posterior, Primary | 95 |
| D2410 | Gold foil – one surface | 250 |
| D2420 | Gold foil – two surfaces | 275 |
| PAIN MANAGEMENT AND ADJUNCTIVE SERVICES | ||
| D9110 | Palliative (emergency) treatment dental pain – minor procedure | 35 |
| D9220 | Deep sedation/general anesthesia – first 30 minutes | 90 |
| D9221 | Deep sedation/general anesthesia – (each additional 15 minutes) | 90 |
| D9230 | Inhalation of nitrous oxide/analgesia, anxiolysis | 90 |
| D9241 | Intravenous conscious sedation/analgesia – first 30 minutes | 140 |
| D9310 | Physician | 35 |
| D9410 | House/extended care facility call | 35 |
| D9420 | Hospital or ambulatory surgical center call | 35 |
| D9440 | Office visit – after regular office hours | 35 |
| D9450 | Case Presentaion, Detailed and Extensive Treatment Planning | 35 |
| D4210 | Gingivectomy or gingivoplasty – Four or more contiguous teeth or tooth bounded spaces per quad | 160 |
| D4211 | Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quad | 50 |
| D4230 | Anatomical Crown Exposure (Four or more Contiguous teeth per quadrant) | 160 |
| D4231 | Anatomical Crown Exposure (one to two teeth per quadrant) | 50 |
| D4240 | Spaces per quad | 275 |
| D4241 | Spaces per quad | 275 |
| D4249 | Clinical crown lengthening – hard tissue | 300 |
| D4260 | Bounded spaces per quad | 300 |
| D4261 | Bounded spaces per quad | 300 |
| D4263 | Bone replacement graft – first site in quad | 325 |
| D4264 | Bone replacement graft – each additional site in quad | 250 |
| D4270 | Pedicle soft tissue graft procedure | 325 |
| D4271 | Free soft tissue graft procedure (including donor site surgery) | 325 |
| D4273 | Sub epithelial connective tissue graft procedures, per tooth | 375 |
| D4275 | Soft tissue allograft | 325 |
| D4320 | Provisional splinting – intracoronal | 180 |
| D4321 | Provisional splinting – extracoronal | 150 |
| D4341 | Periodontal scaling and root planning – four or more teeth per quad | 80 |
| D4342 | Periodontal scaling and root planning – one to three teeth per quad | 80 |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | 65 |
| D5410 | Adjust complete denture – maxillary | 30 |
| D5411 | Adjust complete denture – mandibular | 30 |
| D5421 | Adjust partial denture – maxillary | 30 |
| D5422 | Adjust partial denture – mandibular | 30 |
| D5510 | Repair broken complete denture base | 50 |
| D5520 | Replace missing or broken teeth – complete denture (each tooth) | 45 |
| D5610 | Repair resin denture base | 50 |
| D5620 | Repair cast framework | 75 |
| D5630 | Repair or replace broken clasp | 60 |
| D5640 | Replace broken teeth – per tooth | 45 |
| D5650 | Add tooth to existing partial denture | 55 |
| D5660 | Add clasp to existing partial denture | 75 |
| D5710 | Rebase complete maxillary denture | 160 |
| D5711 | Rebase complete mandibular denture | 200 |
| D5720 | Rebase maxillary partial denture | 200 |
| D5721 | Rebase mandibular partial denture | 200 |
| D5730 | Reline complete maxillary denture (chairside) | 95 |
| D5731 | Reline complete mandibular denture (chairside) | 95 |
| D5740 | Reline maxillary partial denture (chairside) | 110 |
| D5741 | Reline mandibular partial denture (chairside) | 110 |
| D5750 | Reline complete maxillary denture (lab) | 130 |
| D5751 | Reline complete mandibular denture (lab) | 130 |
| D5760 | Reline maxillary partial denture (lab) | 160 |
| D5761 | Reline mandibular partial denture (lab) | 160 |
| D5850 | Tissue conditioning, maxillary | 50 |
| D5851 | Tissue conditioning, mandibular | 50 |
| D6090 | Repair implant supported prosthesis | 130 |
| D6091 | prosthesis, per attachment | 130 |
| D6092 | Recement implant/abutment supported crown | 130 |
| D6093 | Recement implant/abutment supported fixed partial denture | 130 |
| D6095 | Repair implant abutment | 130 |
| D6100 | Implant removal | 40 |
| D6930 | Recement fixed partial denture | 40 |
| EXTRACTIONS AND OTHER ORAL SURGERY | ||
| D7111 | Extraction, coronal remnants, deciduous tooth | 60 |
| D7140 | Extraction, erupted tooth or exposed root | 50 |
| D7210 | Surgical removal of erupted tooth | 90 |
| D7220 | Removal of impacted tooth – soft tissue | 120 |
| D7230 | Removal of impacted tooth – partial bony | 140 |
| D7240 | Removal of impacted tooth – completely bony | 160 |
| D7241 | Removal of impacted tooth – completely bony, with unusual surgical complications | 170 |
| D7250 | Surgical removal residual tooth roots (cutting procedure) | 85 |
| D7260 | Oroantral fistula closure | 225 |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | 225 |
| D7280 | Surgical access of an unerupted tooth | 250 |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | 80 |
| D7283 | Placement of Device to Facilitate Eruption of Impacted tooth | 80 |
| D7285 | Biopsy of oral tissue – hard (bone, tooth) | 425 |
| D7286 | Biopsy of oral tissue – soft | 180 |
| D7310 | Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quad | 75 |
| D7311 | Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quad | 75 |
| D7320 | Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quad | 100 |
| D7321 | Alveoloplasty not in conjunction with extractions -one to three teeth or tooth spaces, per quad | 100 |
| D7340 | Vestibuloplasty – uncomplicated | 975 |
| D7350 | Vestibuloplasty – complicated | 925 |
| D7410 | Excision of benign lesion up to 1.25 cm | 650 |
| D7411 | Excision of benign lesion greater than 1.25 cm | 650 |
| D7412 | Excision of benign lesion, complicated | 650 |
| D7413 | Excision of malignant lesion up to 1.25 cm | 800 |
| D7414 | Excision of malignant lesion greater than 1.25 cm | 800 |
| D7415 | Excision of malignant lesion, complicated | 800 |
| D7440 | Excision of malignant tumor – lesion diameter up to 1.25 cm | 800 |
| D7441 | Excision of malignant tumor – lesion diameter greater than 1.25 cm | 800 |
| D7450 | Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm | 650 |
| D7451 | Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1 .25 cm | 650 |
| D7460 | Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1 .25 cm | 650 |
| D7461 | Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm | 650 |
| D7471 | Removal of lateral exostosis (maxilla or mandible) | 450 |
| D7472 | Removal of torus palatinus | 450 |
| D7473 | Removal of torus mandibularis | 450 |
| D7485 | Surgical reduction of osseous tuberosity | 550 |
| D7510 | Incision and drainage of abscess – intraoral soft tissue | 120 |
| D7511 | Multiple fascial spaces | 575 |
| D7520 | Incision and drainage of abscess – extraoral soft tissue | 562 |
| D7521 | Multiple fascial spaces | 575 |
| D7530 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | 200 |
| D7540 | Removal of reaction producing foreign bodies, musculoskeletal system | 225 |
| D7550 | Partial ostectomy/sequestrectomy for removal of non-vital bone | 140 |
| D7560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | 925 |
| D7610 | Maxilla – open reduction (simple) | 925 |
| D7620 | Maxilla – closed reduction (simple) | 925 |
| D7630 | Mandible – open reduction (simple) | 75 |
| D7640 | Mandible – closed reduction (simple) | 100 |
| D7650 | Malar and/or zygomatic arch – open reduction (simple) | 925 |
| D7660 | Malar and/or zygomatic arch – closed reduction (simple) | 650 |
| D7670 | Alveolus – closed reduction, may include stabilization of teeth (simple) | 850 |
| D7671 | Alveolus – open reduction, may include stabilization of teeth (simple) | 450 |
| D7710 | Maxilla – open reduction (compound) | 925 |
| D7720 | Maxilla – closed reduction (compound) | 925 |
| D7730 | Mandible – open reduction (compound) | 100 |
| D7740 | Mandible – closed reduction (compound) | 100 |
| D7750 | Malar and/or zygomatic arch – open reduction (compound) | 400 |
| D7760 | Malar and/or zygomatic arch – closed reduction (compound) | 400 |
| D7770 | Alveolus – open reduction stabilization of teeth (compound) | 450 |
| D7771 | Alveolus – closed reduction stabilization of teeth (compound) | 850 |
| D7960 | Another | 100 |
| D7963 | Frenuloplasty | 100 |
| D7970 | Excision of hyperplastic tissue – per arch | 100 |
| D7971 | Excision of pericoronal gingiva | 85 |
| D9120 | Fixed Partial Denture Sectioning | 40 |
| CROWNS AND MAJOR SERVICES | ||
| D2510 | Inlay – metallic – one surface | 225 |
| D2520 | Inlay – metallic – two surfaces | 250 |
| D2530 | Inlay – metallic – three or more surfaces | 400 |
| D2542 | Onlay – metallic – two surfaces | 300 |
| D2543 | Onlay – metallic – three surfaces | 325 |
| D2544 | Onlay – metallic – four or more surfaces | 350 |
| D2610 | Inlay – porcelain/ceramic – one surface | 250 |
| D2620 | Inlay – porcelain/ceramic – two surfaces | 275 |
| D2630 | Inlay – porcelain/ceramic – three or more surfaces | 425 |
| D2642 | Onlay – porcelain/ceramic – two surfaces | 325 |
| D2643 | Onlay – porcelain/ceramic – three surfaces | 350 |
| D2644 | Onlay – porcelain/ceramic – four or more surfaces | 375 |
| D2650 | Inlay – resin-based composite – one surface | 225 |
| D2651 | Inlay – resin-based composite – two surfaces | 250 |
| D2652 | Inlay – resin-based composite – three or more surfaces | 325 |
| D2662 | Onlay – resin-based composite – two surfaces | 275 |
| D2663 | Onlay – resin-based composite – three surfaces | 325 |
| D2664 | Onlay – resin-based composite – four or more surfaces | 325 |
| D2710 | Crown – resin-based composite (indirect) | 190 |
| D2712 | Crown- 3/4 resin-based composite, indirect | 190 |
| D2720 | Crown – resin with high noble metal | 375 |
| D2721 | Crown – resin with predominantly base metal | 375 |
| D2722 | Crown – resin with noble metal | 375 |
| D2740 | Crown – porcelain/ceramic substrate | 375 |
| D2750 | Crown – porcelain fused to high noble metal | 375 |
| D2751 | Crown – porcelain fused to predominantly base metal | 375 |
| D2752 | Crown – porcelain fused to noble metal | 375 |
| D2780 | Crown – 3/4 cast high noble metal | 375 |
| D2781 | Crown – 3/4 cast predominantly base metal | 375 |
| D2782 | Crown – 3/4 cast noble metal | 375 |
| D2783 | Crown – 3/4 porcelain/ceramic | 375 |
| D2790 | Crown – full cast high noble metal | 375 |
| D2791 | Crown – full cast predominantly base metal | 375 |
| D2792 | Crown – full cast noble metal | 375 |
| D2794 | Crown-Titanium | 375 |
| D2910 | Recement inlay, onlay, or partial coverage restoration | 35 |
| D2915 | Recement cast or prefabricated post and core | 35 |
| D2920 | Recement crown | 35 |
| D2930 | Prefabricated stainless steel crown – primary tooth | 80 |
| D2931 | Prefabricated stainless steel crown – permanent tooth | 90 |
| D2932 | Prefabricated resin crown | 130 |
| D2933 | Prefabricated stainless steel crown with resin window | 140 |
| D2934 | Prefabricated esthetic-coded stainless steel crown primary tooth | 80 |
| D2940 | Protective restoration | 30 |
| D2950 | Crown buildup – including any pins | 80 |
| D2951 | Pin retention – per tooth in addition to restoration | 25 |
| D2952 | Post and core in addition to crown, indirectly fabricated | 110 |
| D2954 | Prefabricated post & core in addition to crown | 130 |
| D2955 | Post removal (not in conjunction with endodontic therapy) | 90 |
| D2970 | Temporary crown (fractured tooth) | 85 |
| D2980 | Crown repair | 190 |
| D3110 | Pulp cap – direct (excluding final restoration) | 20 |
| D3120 | Pulp cap – indirect (excluding final restoration) | 20 |
| D3220 | Therapeutic pulpotomy (excluding final restoration) | 50 |
| D3222 | Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development | 50 |
| D3230 | Pulpal therapy – anterior, primary tooth (excluding final restoration) | 50 |
| D3240 | Pulpal therapy – posterior, primary tooth (excluding final restoration) | 50 |
| D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | 225 |
| D3320 | Endodontic therapy, bicuspid tooth (excluding final restoration) | 275 |
| D3330 | Endodontic therapy, molar (excluding final restoration) | 375 |
| D3346 | Retreatment of previous root canal therapy- anterior | 200 |
| D3347 | Retreatment of previous root canal therapy- bicuspid | 250 |
| D3348 | Retreatment of previous root canal therapy- molar | 325 |
| D3351 | Apexification/recalcification/pulpal regeneration – initial visit | 160 |
| D3352 | Apexification/recalcification/pulpal regeneration – interim medication replacement | 40 |
| D3353 | Apexification/recalcification – final visit | 80 |
| D3410 | Apicoectomy/periradicular surgery – anterior | 170 |
| D3421 | Apicoectomy/periradicular surgery – bicuspid (first root) | 325 |
| D3425 | Apicoectomy/periradicular surgery – molar (first root) | 400 |
| D3426 | Apicoectomy/periradicular surgery (each additional root) | 130 |
| D3430 | Retrograde filling – per root | 95 |
| D3450 | Root amputation – per root | 190 |
| D3920 | Hemisection – (including root removal); not including root canal therapy | 150 |
| D3950 | Canal preparation and fitting of preformed dowel or post | 65 |
| MAJOR PROSTHETIC SERVICES | ||
| D5110 | Complete denture – maxillary | 525 |
| D5120 | Complete denture – mandibular | 525 |
| D5130 | Immediate denture – maxillary | 525 |
| D5140 | Immediate denture – mandibular | 525 |
| D5211 | Maxillary partial denture – resin base (including any conventional clasps, rests, and teeth) | 375 |
| D5212 | Mandibular partial denture – resin base (including any conventional clasps, rests, and teeth) | 375 |
| D5213 | Max partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) | 550 |
| D5214 | Mand partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) | 550 |
| D5225 | Maxillary partial denture – flexible base (including clasps, rests, and teeth) | 550 |
| D5226 | Mandibular partial denture – flexible base (including clasps, rests, and teeth) | 550 |
| D5281 | Removable unilateral partial denture – one piece cast metal (including clasps and teeth) | 350 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | 45 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | 45 |
| D5810 | Interim complete denture (maxillary) | 250 |
| D5811 | Interim complete denture (mandibular) | 300 |
| D5820 | Interim partial denture (maxillary) | 200 |
| D5821 | Interim partial denture (mandibular) | 225 |
| D6010 | Surgical placement of implant body: endosteal implant | 650 |
| D6012 | Surgical Placement of interim implant body for transitional prosthesis: endosteal implant | 650 |
| D6040 | Surgical placement : eposteal implant | 650 |
| D6050 | Surgical placement : transosteal implant | 650 |
| D6056 | Prefabricated abutment- includes placement | 650 |
| D6057 | Custom abutment- includes placement | 650 |
| D6058 | Abutment-Supported Porcelain/ceramic crown | 375 |
| D6059 | Abutment-Supported Porcelain fused to metal crown (high noble metal) | 375 |
| D6060 | Abutment-Supported Porcelain fused to metal crown (predominantly base metal) | 375 |
| D6061 | Abutment-Supported Porcelain fused to metal crown (noble Base) | 375 |
| D6062 | Abutment-Supported Cast Metal Crown (high noble metal) | 375 |
| D6063 | Abutment-Supported Cast Metal Crown (predominatly base metal) | 375 |
| D6064 | Abutment-Supported Cast Metal Crown (noble metal) | 375 |
| D6065 | Implant Supported Porcelain/Ceramic Crown | 375 |
| D6066 | Implant Supported Porcelain Fused to Metal Crown (titanium, titanium alloy, high noble metal) | 375 |
| D6067 | Implant Supported Metal Crown (titanium, titanium alloy, high noble metal) | 375 |
| D6068 | Abutment Supported Retainer for Porcelain/Ceramic FPD | 375 |
| D6069 | Abutment Supported Retainer for Porcelain Fused to Metal FPD (high noble metal) | 375 |
| D6070 | Abutment Supported Retainer for Porcelain Fused to Metal FPD (predominantly base metal) | 375 |
| D6071 | Abutment Supported Retainer for Porcelain Fused to Metal FPD (noble metal) | 375 |
| D6072 | Abutment Supported Retainer for Cast Metal FPD (high noble metal) | 375 |
| D6073 | Abutment Supported Retainer for Cast Metal FPD (predominantly base metal) | 375 |
| D6074 | Abutment Supported Retainer for Cast Metal FPD (noble metal) | 375 |
| D6075 | Implant-Supported Retainer for Ceramic FPD | 375 |
| D6076 | Noble metal | 375 |
| D6077 | Impant- Supported Retainer for Cast Metal FPD (titanium, titanium alloy, or high noble metal) | 375 |
| D6078 | Implant/Abutment-Supported Fixed Denture for Completely Edentulous Arch | 375 |
| D6079 | Impant/Abutment-Supported Fixed Denture for Partially Edentulous Arch | 375 |
| D6080 | Implant maintenance procedures | 225 |
| D6094 | Abutment-Supported Crown (titanium) | 375 |
| D6194 | Abutment-Supported Retainer Crown for FPD (titanium) | 375 |
| D6205 | Pontic (indirect resin-based composite) | 375 |
| D6210 | Pontic – cast high noble metal | 375 |
| D6211 | Pontic – cast predominantly base metal | 375 |
| D6212 | Pontic – cast noble metal | 375 |
| D6214 | Pontic (titanium) | 375 |
| D6240 | Pontic – porcelain fused to high noble metal | 375 |
| D6241 | Pontic – porcelain fused to predominantly base metal | 375 |
| D6242 | Pontic – porcelain fused to noble metal | 375 |
| D6245 | Pontic – porcelain/ceramic | 375 |
| D6250 | Pontic – resin with high noble metal | 375 |
| D6251 | Pontic – resin with predominantly base metal | 375 |
| D6252 | Pontic – resin with noble metal | 375 |
| D6253 | Provisional pontic | 375 |
| D6545 | Cast metal retainer for resin bonded fixed prosthesis | 170 |
| D6548 | Porcelain/ceramic retainer for resin bonded fixed prosthesis | 170 |
| D6600 | Inlay – porcelain/ceramic, two surfaces | 275 |
| D6601 | Inlay – porcelain/ceramic, three or more surfaces | 425 |
| D6602 | Inlay – cast high noble metal, two surfaces | 375 |
| D6603 | Inlay – cast high noble metal, three or more surfaces | 400 |
| D6604 | Inlay – cast predominantly base metal, two surfaces | 375 |
| D6605 | Inlay – cast predominantly base metal, three or more surfaces | 400 |
| D6606 | Inlay – cast noble metal, two surfaces | 375 |
| D6607 | Inlay – cast noble metal, three or more surfaces | 400 |
| D6608 | Onlay – porcelain/ceramic, two surfaces | 325 |
| D6609 | Onlay – porcelain/ceramic, three or more surfaces | 350 |
| D6610 | Onlay – cast high noble metal, two surfaces | 400 |
| D6611 | Onlay – cash high noble metal, three or more surfaces | 425 |
| D6612 | Onlay – cast predominantly base metal, two surfaces | 400 |
| D66I3 | Onlay – cast predominantly base metal, three or more surfaces | 425 |
| D6614 | Onlay – cast noble metal, two surfaces | 400 |
| D6615 | Onlay – cast noble metal, three or more surfaces | 425 |
| D6624 | Inlay (titanium) | 400 |
| D6634 | Onlay (titanium) | 425 |
| D6710 | Crown (indirect resin-based composite) | 375 |
| D6720 | Crown – resin with high noble metal | 375 |
| D6721 | Crown – resin with predominantly base, metal | 375 |
| D6722 | Crown – resin with noble metal | 375 |
| D6740 | Crown – porcelain/ceramic | 375 |
| D6750 | Crown – porcelain fused to high noble metal | 375 |
| D6751 | Crown – porcelain fused to predominantly base metal | 375 |
| D6752 | Crown – porcelain fused to noble metal | 375 |
| D6780 | Crown – 3/4 cast high noble metal | 375 |
| D6781 | Crown – 3/4 cast predominantly base metal | 375 |
| D6782 | Crown – 3/4 cast noble metal | 375 |
| D6783 | Crown – 3/4 porcelain/ceramic | 375 |
| D6790 | Crown – full cast high noble metal | 375 |
| D6791 | Crown – full cast predominantly base metal | 375 |
| D6792 | Crown – full cast noble metal | 375 |
| D6793 | Provisional retainer crown | 375 |
| D6794 | Crown (titanium) | 375 |
| D6970 | Post and core in addition to fixed partial denture retainer, indirectly fabricated | 160 |
| D6972 | Prefabricated post and core in addition to fixed partial denture retainer | 130 |
| D6973 | Core build up for retainer, including any pins | 100 |
| D6975 | Coping – metal | 300 |
