The Industrial Commission has a special bill form for use by dentists. All dentists rendering treatment to Workers’ Compensation claimants must prepare a full itemized statement of services rendered on I.C. Form No.25D, sign the form at the place indicated, and forward two copies to the employer or insurance carrier. The dentist should charge for each service rendered the charge he customarily makes for the same service to the public generally, but not to exceed those set forth below. Procedures not listed below are by report.
Whenever a dentist’s fees exceed those listed herein, complete written additional information must be furnished in order to justify any additional approval.
00100-00999 I. Diagnostic
CLINICAL ORAL EXAMINATIONS
| ADA Code | Description | Allowance |
| 00110 | Initial oral examination | $48.00 |
| 00120 | Periodic oral examination | $48.00 |
| 00130 | Emergency oral examination | $90.50 |
| 00140 | Limited oral examination | $32.00 |
| 00150 | Comprehensive Oral Evaluation | $48.00 |
| 00160 | Detailed oral examination | $90.00 |
RADIOGRAPHS
| ADA Code | Description | Allowance |
| 00210 | Intraoral—complete series agents (including bitewings), by report | $85.00 |
| 00220 | Intraoral—periapical—first film | $15.00 |
| 00230 | Intraoral—periapical each additional film | $12.00 |
| 00240 | Intraoral—occlusal film | $16.00 |
| 00250 | Extraoral—first film | $66.00 |
| 00260 | Extraoral—each additional film | $66.00 |
| 00270 | Bitewings—single film | $15.00 |
| 00272 | Bitewings—two films | $27.00 |
| 00274 | Bitewings—four films | $35.00 |
| 00290 | Posterior—anterior or lateral skull and facial bone survey film | $66.00 |
| 00310 | Sialography | $184.00 |
| 00320 | Temporomandibular joint arthrogram, including injection | $25.00 |
| 00321 | Other temporomandibular joint films | $82.00 |
| 00322 | Tomographic survey | BR |
| 00330 | Panoramic film | $66.00 |
| 00340 | Cephalometric film | $66.00 |
TESTS AND LABORATORY EXAMINATIONS
| ADA Code | Description | Allowance |
| 00415 | Bacteriologic studies for determination of pathologic agents | $26.00 |
| 00425 | Caries susceptibility tests | $30.00 |
| 00460 | Pulp vitality tests | $35.00 |
| 00470 | Diagnostic casts | $52.00 |
| 00471 | Diagnostic photographs | $41.00 |
| 00501 | Histopathologic examinations | $80.00 |
| 00502 | Other oral pathology procedures, by report | $35.00 |
| 00999 | Unspecified diagnostic procedure, by report | BR |
01000-01999 II. PREVENTATIVE
DENTAL PROPHYLAXIS
| ADA Code | Description | Allowance |
| 01110 | Prophylaxis—adult | $48.00 |
| 01120 | Prophylaxis—child | $34.00 |
TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)
| ADA Code | Description | Allowance |
| 01201 | Topical application of fluoride (including prophylaxis)—child | $50.00 |
| 01203 | Topical application of fluoride (excluding prophylaxis)—child | $16.00 |
| 01204 | Topical application of fluoride (excluding prophylaxis)—adult | $18.00 |
| 01205 | Topical application of fluoride (including prophylaxis)—adult | $64.00 |
OTHER PREVENTATIVE SERVICES
| ADA Code | Description | Allowance |
| 01310 | Nutritional counseling for the control of dental disease | $30.00 |
| 01330 | Oral hygiene instruction | $30.00 |
| 01351 | Sealant—per tooth | $32.00 |
SPACE MAINTENANCE (PASSIVE APPLIANCES)
| ADA Code | Description | Allowance |
| 01510 | Space maintainer—fixed unilateral | $237.00 |
| 01515 | Space maintainer—fixed bilateral | $380.00 |
| 01520 | Space maintainer—removable unilateral | $279.00 |
| 01525 | Space maintainer—removable bilateral | $197.00 |
| 01550 | Recommendation. of space maintainer | $33.00 |
02000-02999 III. RESTORATIVE
AMALGAM RESTORATIONS (INCLUDING POLISHING)
| ADA Code | Description | Allowance |
| 02110 | Amalgam—one surface, primary | $62.00 |
| 02120 | Amalgam—two surfaces, primary | $82.00 |
| 02130 | Amalgam—three surfaces, primary | $97.00 |
| 02131 | Amalgam—four or more surfaces, primary | $121.00 |
| 02140 | Amalgam—one surface, permanent | $73.00 |
| 02150 | Amalgam—two surfaces, permanent | $88.00 |
| 02160 | Amalgam—three surfaces, permanent | $102.00 |
| 02161 | Amalgam—four or more surfaces, permanent | $132.00 |
SILICATE RESTORATIONS
| ADA Code | Description | Allowance |
| 02210 | Silicate cement—per restoration | $46.00 |
RESIN RESTORATIONS
| ADA Code | Description | Allowance |
| 02330 | Resin—one surface, anterior | $75.00 |
| 02331 | Resin—two surfaces, anterior | $92.00 |
| 02332 | Resin—three surfaces, anterior | $109.00 |
| 02335 | Resin—four or more surfaces or involving incisal angle, anterior | $132.00 |
| 02336 | Composite resin crown anterior—primary | $125.00 |
| 02380 | Resin—one surface, posterior—primary | $78.00 |
| 02381 | Resin—two surfaces, posterior—primary | $113.00 |
| 02382 | Resin—three or more surfaces, posterior—primary | $151.00 |
| 02385 | Resin—one surface, posterior—permanent | $93.00 |
| 02386 | Resin—two surfaces, posterior—permanent | $124.00 |
| 02387 | Resin—three or more surfaces, posterior—permanent | $172.00 |
GOLD FOIL RESTORATIONS
| ADA Code | Description | Allowance |
| 02410 | Gold foil—one surface | BR |
| 02420 | Gold foil—two surfaces | BR |
| 02430 | Gold foil—three surfaces | BR |
INLAY RESTORATIONS
| ADA Code | Description | Allowance |
| 02510 | Inlay—metallic—one surface | $382.00 |
| 02520 | Inlay—metallic—two surfaces | $442.00 |
| 02530 | Inlay—metallic—three surfaces | $492.00 |
| 02540 | Onlay—metallic—per tooth (in addition to inlay) | $592.00 |
| 02543 | Onlay—metallic—three surface | $594.00 |
| 02544 | Onlay—metallic—four surface | $612.00 |
| 02610 | Inlay—porcelain/ceramic—one surface | $357.00 |
| 02620 | Inlay—porcelain/ceramic—two surfaces | $412.00 |
| 02630 | Inlay—porcelain/ceramic—three surfaces | $495.00 |
| 02640 | Onlay—porcelain/ceramic—per tooth ( in addition to inlay) | BR |
| 02650 | Inlay—composite/resin—one surface (laboratory processed) | BR |
| 02651 | Inlay—composite/resin—two surfaces (laboratory processed) | BR |
| 02652 | Inlay—composite/resin—three surfaces (laboratory processed) | BR |
| 02660 | Onlay—composite/resin—per tooth ( in addition to inlay laboratory processed) | BR |
CROWNS—SINGLE RESTORATION ONLY
| ADA Code | Description | Allowance |
| 02710 | Crown—resin (laboratory) | $145.00 |
| 02720 | Crown—resin with high noble metal | $504.00 |
| 02721 | Crown—resin with predominantly base metal | $504.00 |
| 02722 | Crown—resin with noble metal | $504.00 |
| 02740 | Crown—porcelain/ceramic substrate | $742.00 |
| 02750 | Crown—porcelain fused to high noble metal | $708.00 |
| 02751 | Crown—porcelain fused to predominantly base metal | $504.00 |
| 02752 | Crown—porcelain fused to noble metal | $504.00 |
| 02790 | Crown—full cast high noble metal | $654.00 |
| 02791 | Crown—full cast predominantly base metal | $504.00 |
| 02810 | Crown—3/4 cast metallic | $654.00 |
OTHER RESTORATIVE SERVICES
| ADA Code | Description | Allowance |
| 02910 | Recement inlay | $76.00 |
| 02920 | Recement crown | $76.00 |
| 02930 | Prefabricated stainless steel crown—primary tooth | $135.00 |
| 02931 | Prefabricated stainless steel crown—permanent tooth | $172.00 |
| 02932 | Prefabricated resin crown | $172.00 |
| 02933 | Prefabricated stainless steel crown with resin window | $189.00 |
| 02940 | Sedative filling | $76.00 |
| 02950 | Core buildup, including any pins | $142.00 |
| 02951 | Pin retention—per tooth, in addition to restoration | $41.00 |
| 02952 | Cast post and core in addition to crown | $247.00 |
| 02954 | Prefabricated post and core in addition to crown | $154.00 |
| 02960 | Labial veneer (laminate) chairside | $150.00 |
| 02961 | Labial veneer (laminate) laboratory | BR |
| 02962 | Labial veneer (resin laminate) laboratory | $542.00 |
| 02970 | Temporary crown (fractured tooth) | $137.00 |
| 02980 | Crown repair, by report | BR |
| 02999 | Unspecified restorative procedure, by report | BR |
03000-03999 IV. ENDODONTICS
PULP CAPPING
| ADA Code | Description | Allowance |
| 03110 | Pulp cap—direct (excluding final restoration) | $36.00 |
| 03120 | Pulp cap—indirect (excluding final restoration) | $42.00 |
PULPOTOMY
| ADA Code | Description | Allowance |
| 03220 | Therapeutic pulpotomy (excluding final restoration) Root canal therapy (including treatment plan, clinical procedures, and follow-up care) | $121.00 |
| 03310 | Anterior (excluding final restoration) | $322.00 |
| 03320 | Bicuspid (excluding final restoration) | $424.00 |
| 03330 | Molar (excluding final restoration) | $572.00 |
| 03346 | Retreatment—anterior | $432.00 |
| 03347 | Retreatment—bicusbid | $562.00 |
| 03348 | Retreatment—molar | $642.00 |
| 03351 | Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) | $162.00 |
| 03352 | Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | $110.00 |
| 03353 | Apexification/recalcification final visit (includes completed root canal therapy—apical closure/calcific repair of perforations, root resorption, etc.) | $432.00 |
PERIAPICAL SERVICES
| ADA Code | Description | Allowance |
| 03410 | Apicoectomy/Periradicular surgery—anterior | $632.00 |
| 03421 | Apicoectomy/Periradicular surgery—bicuspid (first root) | $660.00 |
| 03425 | Apicoectomy/Periradicular surgery—molar (first root) | $740.00 |
| 03426 | Apicoectomy/Periradicular surgery (each additional root) | BR |
| 03430 | Retrograde filling—per root | $82.00 |
| 03450 | Root amputation—per root | $210.00 |
| 03460 | Endodontic endosseous implant | BR |
| 03470 | Intentional replantation (including necessary splinting) | BR |
OTHER ENDODONTIC PROCEDURES
| ADA Code | Description | Allowance |
| 03910 | Surgical procedure for isolation of tooth with rubber dam | $126.00 |
| 03920 | Hemisection (including any root removal), not including root canal therapy | $210.00 |
| 03950 | Canal preparation and fitting of preformed dowel or post | BR |
| 03960 | Bleaching of discolored tooth | $210.00 |
| 03999 | Unspecified endodontic procedure | BR |
04000-04999 V. PERIODONTICS
SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE SERVICES)
| ADA Code | Description | Allowance |
| 04210 | Gingivectomy or gingivoplasty—per quadrant | $372.00 |
| 04211 | Gingivectomy or gingivoplasty—per tooth | $61.00 |
| 04220 | Gingival cuterrage, surgical, per quadrant, by report | $210.00 |
| 04240 | Gingival flap procedure, including root planing—per quadrant | $372.00 |
| 04249 | Crown lengthening—hard and soft tissue, by report | $272.00 |
| 04250 | Mucogingival surgery—per quadrant | BR |
| 04260 | Osseous surgery (including flap entry and closure)—per quadrant | $472.00 |
| 04261 | Bone replacement graft—single site (including flap entry and closure) | $272.00 |
| 04262 | Bone replacement graft multiple sites (including flap entry and closure) | BR |
| 04268 | Guided tissue regeneration (includes the surgery and reentry) | BR |
| 04270 | Pedicle soft tissue graft procedure | BR |
| 04271 | Free soft tissue graft procedure (including donor site) | BR |
ADJUNCTIVE PERIODONTAL SERVICES
| ADA Code | Description | Allowance |
| 04320 | Provisional splinting—intracoronal | BR |
| 04321 | Provisional splinting—extracoronal | $124.00 |
| 04341 | Periodontal scaling and root planing—per quadrant | $135.00 |
| 04345 | Periodontal scaling performed in the presence of gingival inflammation | BR |
| 04381 | Periodontal scaling per tooth | $48.00 |
OTHER PERIODONTAL SERVICES
| ADA Code | Description | Allowance |
| 04910 | Periodontal maintenance procedures (following active therapy) | $72.00 |
| 04920 | Unscheduled dressing change (by someone other than treating dentist) | BR |
| 04999 | Unspecified periodontal procedure, by report | BR |
05000-05899 VI. PROSTHODONTICS (REMOVABLE)
COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE)
| ADA Code | Description | Allowance |
| 05110 | Complete upper | $810.00 |
| 05120 | Complete lower | $810.00 |
| 05130 | Immediate upper | $810.00 |
| 05140 | Immediate lower | $810.00 |
PARTIAL DENTURES (INCLUDING ROUTINE POSTDELIVERY CARE)
| ADA Code | Description | Allowance |
| 05211 | Upper partial—resin base (including any conventional clasps, rests and teeth) | $424.00 |
| 05212 | Lower partial—resin base (including any conventional clasps, rests and teeth) | $424.00 |
| 05213 | Upper partial—cast metal base with resin saddles (including any conventional clasps, rests and teeth) | $950.00 |
| 05214 | Lower partial—cast metal base with resin saddles (including any conventional clasps, rests and teeth | $950.00 |
| 05281 | Removable unilateral partial denture—one piece cast metal, (including clasps and pontics) | $950.00 |
| No code | Upper precision—partial, fitted to crowns | $1275.00 |
| No code | Lower precision—partial, fitted to crowns | $1275.00 |
ADJUSTMENTS TO REMOVABLE PROSTHESES
| ADA Code | Description | Allowance |
| 05410 | Adjust complete denture—upper | $39.00 |
| 05411 | Adjust complete denture—lower | $39.00 |
| 05421 | Adjust partial denture—upper | $39.00 |
| 05422 | Adjust partial denture—lower | $39.00 |
REPAIRS TO COMPLETE DENTURES
| ADA Code | Description | Allowance |
| 05510 | Repair broken complete denture base | $132.00 |
| 05520 | Replace missing or broken teeth—complete denture (each tooth) | $124.00 |
REPAIRS TO PARTIAL DENTURES
| ADA Code | Description | Allowance |
| 05610 | Repair resin saddle or base | $124.00 |
| 05620 | Repair cast framework | $212.00 |
| 05630 | Repair or replace broken clasp | $210.00 |
| 05640 | Replace broken teeth—per tooth | $104.00 |
| 05650 | Add tooth to existing partial denture | $132.00 |
| 05660 | Add clasp to existing partial denture | $232.00 |
DENTURE REBASE PROCEDURES
| ADA Code | Description | Allowance |
| 05710 | Rebase complete upper denture | $272.00 |
| 05711 | Rebase complete lower denture | $272.00 |
| 05720 | Rebase upper partial denture | $242.00 |
| 05721 | Rebase lower partial denture | $242.00 |
DENTURE RELINE PROCEDURES
| ADA Code | Description | Allowance |
| 05730 | Reline complete upper denture (chairside) | $139.00 |
| 05731 | $Reline complete lower denture (chairside) | $139.00 |
| 05740 | Reline upper partial denture (chairside) | $139.00 |
| 05741 | Reline lower partial denture (chairside) | $139.00 |
| 05750 | Reline complete upper denture (laboratory) | $236.00 |
| 05751 | Reline complete lower denture (laboratory) | $236.00 |
| 05760 | Reline upper partial denture (laboratory) | $236.00 |
| 05761 | Reline lower partial denture (laboratory) | $236.00 |
OTHER REMOVABLE PROSTHETIC SERVICES
| ADA Code | Description | Allowance |
| 05810 | Interim complete denture (upper) | $450.00 |
| 05811 | Interim complete denture (lower) | $450.00 |
| 05820 | Interim partial denture (upper) | $450.00 |
| 05821 | Interim partial denture (lower) | $450.00 |
| 05850 | Tissue conditioning, upper—per denture unit | $72.00 |
| 05851 | Tissue conditioning, lower—per denture unit | $72.00 |
| 05860 | Overdenture—complete | $1050.00 |
| 05861 | Overdenture—partial | BR |
| 05862 | Precision attachment | $286.00 |
| 05899 | Unspecified removable prosthodontic procedure | BR |
05900-05999 VII. MAXILLOFACIAL PROSTHETICS
MAXILLOFACIAL PROSTHETICS
| ADA Code | Description | Allowance |
| 05911 | Facial moulage (sectional) | BR |
| 05912 | Facial moulage (complete) | BR |
| 05913 | Nasal prosthesis | $1455.00 |
| 05914 | Auricular prosthesis | $1698.00 |
| 05915 | Orbital prosthesis | $2183.00 |
| 05916 | Ocular prosthesis | $1455.00 |
| 05919 | Facial prosthesis | $728.00 |
| 05922 | Nasal septal prosthesis | BR |
| 05923 | Ocular prosthesis, interim | BR |
| 05924 | Cranial prosthesis | BR |
| 05925 | Facial augmentation implant prosthesis | BR |
| 05926 | Nasal prosthesis, replacement | BR |
| 05927 | Auricular prosthesis, replacement | BR |
| 05928 | Orbital prosthesis, replacement | BR |
| 05929 | Facial prosthesis, replacement | BR |
| 05931 | Obturator prosthesis, surgical | $728.00 |
| 05932 | Obturator prosthesis, definitive | $2183.00 |
| 05933 | Obturator prosthesis, modification | $509.00 |
| 05934 | Mandibular resection prosthesis with guide flange | $1698.00 |
| 05935 | Mandibular resection prosthesis with guide flange | $1698.00 |
| 05936 | Obturator prosthesis, interim | BR |
| 05937 | Trismus appliance (not for TMD treatment) | BR |
| 05951 | Feeding Aid | $728.00 |
| 05952 | Speech aid prosthesis, pediatric | $1698.00 |
| 05953 | Speech aid prosthesis, adult | $2183.00 |
| 05954 | Palatal augmentation prosthesis | $2183.00 |
| 05955 | Palatal lift prosthesis, modification | $2183.00 |
| 05958 | Palatal lift prosthesis, interim | BR |
| 05959 | Palatal lift prosthesis, modification | BR |
| 05960 | Speech aid prosthesis, modification | BR |
| 05982 | Surgical stent | $1091.00 |
| 05983 | Radiation carrier | $1698.00 |
| 05984 | Radiation shield | $1091.00 |
| 05985 | Radiation cone locator | $1091.00 |
| 05986 | Fluoride gel carrier | $72.00 |
| 05987 | Commissure splint | BR |
| 05988 | Surgical splint | BR |
| 05999 | Unspecified maxillofacial prosthesis | BR |
06000-061999 VIII. IMPLANT SERVICES
| ADA Code | Description | Allowance |
| 06030 | Endosseous implant (in the bone) | BR |
| 06040 | Subperiosteal implant | BR |
| 06050 | Transosseous implant | BR |
| 06055 | Implant connecting bar | BR |
| 06080 | Implant maintenance procedures, including; removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis | BR |
| 06090 | Repair implant | BR |
| 06100 | Impant removal | BR |
| 06199 | Unspecified implant procedure, by report | BR |
06200-06999 IX. PROSTHODONTICS, FIXED (EACH ABUTMENT AND EACH PONTIC CONSTITUTE A UNIT IN A BRIDGE)
BRIDGE PONTICS
| ADA Code | Description | Allowance |
| 06210 | Pontic—cast high noble metal | $672.00 |
| 06211 | Pontic—cast predominantly base metal | $642.00 |
| 06212 | Pontic—cast noble metal | $672.00 |
| 06240 | Pontic—porcelain fused to high noble metal | $672.00 |
| 06241 | Pontic—porcelain fused to predominantly base metal | $642.00 |
| 06242 | Pontic—porcelain fused to noble metal | $672.00 |
| 06250 | Pontic—resin with high noble metal | $504.00 |
| 06251 | Pontic—resin with predominantly base metal | $504.00 |
| 06252 | Pontic—resin with noble metal | $504.00 |
RETAINERS
| ADA Code | Description | Allowance |
| 06520 | Inlay—metallic—two surfaces | $504.00 |
| 06530 | Inlay—metallic—three or more surfaces | $572.00 |
| 06540 | Onlay—metallic—per tooth (in addition to inlay) | BR |
| 06545 | Retainer—cast metal for acid etched fixed prosthesis | $324.00 |
BRIDGE RETAINERS—CROWNS
| ADA Code | Description | Allowance |
| 06720 | Crown—resin with high noble metal | $504.00 |
| 06721 | Crown—resin with predominantly base metal | $504.00 |
| 06722 | Crown—resin with noble metal | $504.00 |
| 06750 | Crown—porcelain fused to high noble metal | $672.00 |
| 06751 | Crown—porcelain fused to predominantly base metal | $672.00 |
| 06752 | Crown—porcelain fused to noble metal | $672.00 |
| 06780 | Crown—3/4 cast noble metal | $672.00 |
| 06790 | Crown—full cast high noble metal | $672.00 |
| 06791 | Crown—full cast predominantly base metal | $642.00 |
| 06792 | Crown—full cast noble metal | $672.00 |
OTHER FIXED PROSTHETIC SERVICES
| ADA Code | Description | Allowance |
| 06930 | Recement bridge | $105.00 |
| 06940 | Stress breaker | $145.00 |
| 06950 | Precision attachment | $286.00 |
| 06970 | Cast post and core in addition to bridge retainer | $247.00 |
| 06971 | Cast post as part of bridge retainer | $82.50 |
| 06972 | Prefabricated post and core in addition to bridge retainer | $154.00 |
| 06973 | Core build up for retainer, including any pins | $142.00 |
| 06975 | Coping—metal | BR |
| 06980 | Bridge repair, by report | BR |
| 06999 | Unspecified fixed prosthetic procedure, by report | BR |
07000-07999 X. ORAL SURGERY
EXTRACTIONS—INCLUDES LOCAL ANESTHESIA AND ROUTINE POSTOPERATIVE CARE
| ADA Code | Description | Allowance |
| 07110 | Single tooth | $110.00 |
| 07120 | Each additional tooth | $110.00 |
| 07130 | Root removal—exposed roots | $72.00 |
SURGICAL EXTRACTIONS—INCLUDES LOCAL ANETHESIA AND ROUTINE POSTOPERATIVE CARE
| ADA Code | Description | Allowance |
| 07210 | Surgical removal of erupted tooth requiring elevation of mucoperisteal flap and removal of bone and/or section of tooth | $132.00 |
| 07220 | Removal of impacted tooth soft tissue | $142.00 |
| 07230 | Removal of impacted tooth partially bony | $210.00 |
| 07240 | Removal of impacted tooth completely bony | $242.00 |
| 07241 | Removal of impacted tooth completely bony, with unusual surgical complications | $128.50 |
| 07250 | Surgical removal of residual tooth roots (cutting procedure) | $61.50 |
OTHER SURGICAL PROCEDURES
| ADA Code | Description | Allowance |
| 07260 | Oral antral fistula closure | 128.50 |
| 07270 | Tooth reimplantation and/or stabilization of accidental evulsed or displaced tooth and/or alveolus | $382.00 |
| 07271 | Tooth implantation | BR |
| 07272 | Tooth Transplantation | BR |
| 07280 | Surgical exposure of impacted tooth or unerupted tooth for othodontic reasons (including orthodontic attachments) | $310.00 |
| 07281 | Surgical exposure of impacted or unerupted tooth to aid eruption | $210.00 |
| 07285 | Biopsy of oral tissue—hard | $101.50 |
| 07286 | Biopsy of oral tissue—soft | $101.50 |
| 07290 | Surgical repositioning of teeth | BR |
| 07291 | Transseptal fiberotomy | $110.00 |
ALVEOPLASTY—SURGICAL PREPARATION OF RIDGE FOR DENTURES
| ADA Code | Description | Allowance |
| 07310 | Alveoplasty in conjuction with extractions—per quadrant | $82.00 |
| 07320 | Alveoplasty not in conjunction with extractions—per quadrant | $210.00 |
VESTIBULOPLASTY
| ADA Code | Description | Allowance |
| 07340 | Vestibuloplasty—ridge extention (secondary epithelialization) | BR |
| 07350 | Vestibuloplasty—ridge extention (including soft tissue grafts, muscle reattachments, revision of soft tissue attachments, and management of hypertrophied and hyperplastic tissue) | BR |
SURGICAL EXCISION OF REACTIVE INFLAMMITORY LESIONS (SCAR TISSUE OR LOCALIZED CONGENITAL LESIONS)
| ADA Code | Description | Allowance |
| 07410 | Radical excision—lesion diameter up to 1.25 cm | $82.50 |
| 07420 | Radical excision—lesion diameter greater than 1.25 cm | $154.00 |
REMOVAL OF TUMORS, CYSTS AND NEOPLASMS
| ADA Code | Description | Allowance |
| 07430 | Excision of benign tumor—lesion diameter up to 1.25 cm | BR |
| 07431 | Excision of benign tumor—lesion diameter greater than 1.25 cm | BR |
| 07440 | Excision of malignant tumor—lesion diameter up to 1.25 cm | BR |
| 07441 | Excision of malignant tumor—lesion greater than 1.25 cm | BR |
| 07450 | Removal of odontogenic cyst or tumor—lesion diameter up to 1.25 cm | BR |
| 07451 | Removal of odontogenic cyst or tumor—lesion greater than 1.25 cm | $159.50 |
| 07460 | Removal of nonodontogenic cyst or tumor—lesion up to 1.25 cm | $148.50 |
| 07461 | Removal of nonodontagenic cyst or tumor—lesion greater than 1.25 cm | $148.50 |
| 07465 | Destruction of lesion(s) by physical or chemical method | BR |
EXCISION OF BONE TISSUE
| ADA Code | Description | Allowance |
| 07470 | Removal of exostosis—maxilla or mandible | $310.00 |
| 07480 | Partial ostectomy (guttering or saucerization) | $168.50 |
| 07490 | Radical resection of mandible with bone graft | BR |
SURGICAL INCISION
| ADA Code | Description | Allowance |
| 07510 | Incision and drainage of abscess—intraoral soft tissue | $101.50 |
| 07520 | Incision and drainage of abscess—extraoral soft tissue | $101.50 |
| 07530 | Removal of foreign body, skin, reduction with fixation and or subcutaneous areolar tissue | $101.50 |
| 07540 | Removal of reaction—producing foreign bodies—muscuoskeletal system | BR |
| 07550 | Sequestrectomy for osteomyelitis | BR |
| 07560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | BR |
TREATMENT OF FRACTURES—SIMPLE
| ADA Code | Description | Allowance |
| 07610 | Maxilla—open reduction (teeth immobilized if present | BR |
| 07620 | Maxilla—closed reduction | BR |
| 07630 | Mandible—open reduction | BR |
| 07640 | Mandible—closed reduction | BR |
| 07650 | Malar and/or zygomatic arch—open reduction | BR |
| 07660 | Malar and/or zygomatic arch—closed reduction | BR |
| 07670 | Alveolus—stabilization of teeth, open reduction | BR |
| 07680 | Facial bones—complicated reduction with fixation and multiple surgical approaches | BR |
TREATMENT OF FRACTURES—COMPOUND
| ADA Code | Description | Allowance |
| 07710 | Maxilla—open reduction | BR |
| 07720 | Maxilla—closed reduction | BR |
| 07730 | Mandible—open reduction | BR |
| 07740 | Mandible—closed reduction | BR |
| 07750 | Malar and/or zygomatic arch—open reduction | BR |
| 07760 | Malar and/or zygomatic arch—closed reduction | BR |
| 07770 | Alveolus—stabilization of teeth, open reduction splinting | BR |
| 07780 | Facial bones—complicated reduction with fixation and multiple surgical approaches | BR |
TREATMENT OF FRACTURES—COMPOUND
| ADA Code | Description | Allowance |
| 07810 | Open reduction of dislocation | BR |
| 07820 | Closed reduction of dislocation | BR |
| 07830 | Manipulation under anesthesia | BR |
| 07840 | Condylectomy | BR |
| 07850 | Surgical discectomy; with/without implant | BR |
| 07852 | Disc repair | BR |
| 07854 | Synovectomy | BR |
| 07856 | Myotomy | BR |
| 07858 | Joint reconstruction | BR |
| 07860 | Arthrotomy | BR |
| 07865 | Arthroplasty | BR |
| 07870 | Arthrocentesis | BR |
| 07872 | Arthroscopy—diagnosis, with or without biopsy | BR |
| 07873 | Arthroscopy—surgical; lavage and lysis of adhesions | BR |
| 07874 | Arthroscopy—surgical; disc repositioning and stabilization | BR |
| 07875 | Arthroscopy—surgical, synovectomy | BR |
| 07876 | Arthroscopy—surgical, discectomy | BR |
| 07877 | Arthroscopy—surgical, debridement | BR |
| 07880 | Occlusal orthotic device | BR |
| 07899 | Unspecified TMD therapy | BR |
REPAIR OF TRAUMATIC WOUNDS
| ADA Code | Description | Allowance |
| 07910 | Suture of recent small wounds up to 5 cm | $325.00 |
COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE)
| ADA Code | Description | Allowance |
| 07911 | Complicated suture—up to 5 cm | $524.00 |
| 07912 | Complicated suture—greater than 5 cm | BR |
OTHER REPAIR PROCEDURES
| ADA Code | Description | Allowance |
| 07920 | Skin grafts (identify defect covered, location, and type of graft) | BR |
| 07940 | Osteoplasty—for orthognathic deformities | BR |
| 07941 | Osteotomy—ramus, closed | BR |
| 07942 | Osteotomy—ramus, open | BR |
| 07943 | Osteotomy—ramus, open with bone graft | BR |
| 07944 | Osteotomy—segmented or subapical—per sextant or quadrant | BR |
| 07945 | Osteotomy—body of mandible | BR |
| 07946 | LeFort I (maxilla—total) | BR |
| 07947 | LeFort I (maxilla—segmented) | BR |
| 07948 | LeFort II of LeFort III (osteoplasty of facial bone for midface hyoplasia or retrusion)—without bone graft | BR |
| 07949 | LeFort II or LeFort III—with bone graft | BR |
| 07950 | Osseous, osteoperiosteal, periosteal, or cartilage graft of the mandible—autogenous or nonautogenous | BR |
| 07955 | Repair of maxillofacial soft and hard tissue defects | BR |
| 07960 | Frenulectomy (frenectomy or frenotomy) separate procedure | BR |
| 07970 | Excision of hyperplastic tissue—per arch | BR |
| 07971 | Excision of pericoronal gingiva | BR |
| 07980 | Sialolithotomy | $165.00 |
| 07981 | Excision of salivary fistula | BR |
| 07982 | Sialodochoplasty | BR |
| 07983 | Closure of salivary fistula | BR |
| 07990 | Emergency tracheotomy | BR |
| 07991 | Coronoidectomy | BR |
| 07993 | Impact—facial bones (homologous, heterologous, or alloplastic | BR |
| 07994 | Impact—other than facial bones | BR |
| 07999 | Unspecified oral surgery procedure | BR |
08000-08999 XI. 0RTHODONTICS
MINOR TREATMENT FOR TOOTH GUIDANCE
| ADA Code | Description | Allowance |
| 08110 | Removable appliance therapy | BR |
| 08120 | Fixed appliance therapy | BR |
MINOR TREATMENT TO CONTROL HARMFUL HABITS
| ADA Code | Description | Allowance |
| 08210 | Removable appliance therapy | $472.00 |
| 08220 | Fixed appliance therapy | $472.00 |
INTERCEPTIVE ORTHODONTIC TREATMENT
| ADA Code | Description | Allowance |
| 08360 | Removable appliance therapy | BR |
| 08370 | Fixed appliance therapy | BR |
COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION
| ADA Code | Description | Allowance |
| 08460 | Class I malocclusion | BR |
| 08470 | Class II malocclusion | BR |
| 08480 | Class III malocclussion | BR |
COMPREHENSIVE ORTHODONTIC TREATMENT—PERMANENT DENTITION
| ADA Code | Description | Allowance |
| 08560 | Class I malocclusion | BR |
| 08570 | Class II malocclusion | BR |
| 08580 | Class III malocclussion | BR |
OTHER ORTHODONTIC DEVICES
| ADA Code | Description | Allowance |
| 08650 | Treatment for the atypical or extended skeletal case | $450.00 |
| 08750 | Posttreatment stabilization | BR |
| 08999 | Unspecified orthodontic procedure | BR |
09000-09999 XII. ADJUNCTIVE GENERAL SERVICES
UNCLASSIFIED TREATMENT
| ADA Code | Description | Allowance |
| 09110 | Palliative (emergency) treatmentof dental pain—minor procedures | $46.00 |
ANESTHESIA
| ADA Code | Description | Allowance |
| 09210 | Local anesthesia not in conjunction with operative or surgical procedures | $42.00 |
| 09211 | Regional block anesthesia | BR |
| 09212 | Trigeminal division block anesthesia | BR |
| 09215 | Local anesthesia | $42.00 |
| 09220 | General anesthesia—first 30 minutes | BR |
| 09221 | General anesthesia—additional 15 minutes | BR |
| 09230 | Analgesia | BR |
| 09240 | Intravenous sedation | BR |
PROFESSIONAL CONSULTATION
| ADA Code | Description | Former Allowance | Allowance |
| 09310 | Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) | $27.50 | $42.00 |
PROFESSIONAL VISITS
| ADA Code | Description | Former Allowance | Allowance |
| 09410 | House call | BR | BR |
| 09420 | Hospital call | $58.00 | $58.00 |
| 09430 | Office visit for observation (during regularly scheduled hours)—no other services performed | $24.50 | $24.50 |
| 09440 | Office visit—after regularly schedule hours | $48.50 | $48.50 |
DRUGS
| ADA Code | Description | Former Allowance | Allowance |
| 09610 | Therapeutic drug injection | BR | BR |
| 09630 | Other drugs and/or medicaments | BR | BR |
MISCELLANEOUS SERVICES
| ADA Code | Description | Former Allowance | Allowance |
| 09910 | Application of desensitizing medicaments | $27.50 | $35.00 |
| 09920 | Behavior management | BR | BR |
| 09930 | Treatment of complication (post-surgical) unusual circumstances | BR | BR |
| 09940 | Occlusal guards | $247.50 | $310.00 |
| 09941 | Fabrication of athletic mouthguards | BR | $110.00 |
| 09950 | Occlusion analysis—mounted case | BR | $110.00 |
| 09951 | Occlusion adjustment—limited | $82.50 | $82.50 |
| 09952 | Occlusal adjustment—complete | $220.00 | $272.00 |
| 09999 | Unspecified adjustive procedure | BR | BR |
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