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Connection Dental PPO Fee Schedule Proc Code Procedure Description D0000 DIAGNOSTIC SERVICES D0120 Periodic Oral Evaluation D0140 Limited Oral Evaluation - Problem Focused D0145 Oral evaluation, pt < 3yrs D0150 Comprehensive Oral Evaluation D0160 Detailed And Extensive Oral Evaluation - Problem-Focu D0170 D0180 Proc Code Procedure Description 0 D2330 Resin - One Surface, Anterior 98 33 D2331 Resin - Two Surfaces, Anterior 121 50 D2332 Resin - Three Surfaces, Anterior 145 47 D2335 Resin - Four Or More Surfaces Or Involving Incisal Angl 169 54 D2390 Resin-Based Composite Crown, Anterior 190 101 D2391 Resin-Based Composite - One Surface, Posterior 109 Re-Evaluation, Limited, Problem Focused 36 D2392 Resin-Based Composite - Two Surfaces, Posterior 140 Comprehensive Periodontal Evaluation - New Or Establ 59 D2393 Resin-Based Composite - Three Surfaces, Posterior 169 D0190 Screening Of A Patient 13 D2394 Resin-Based Composite - Four Or More Surfaces, Post 217 D0191 Assessment Of A Patient 13 D2499A D0210 Intraoral - Complete Series (Including Bitewings) 90 D2510 INLAY/ONLAY RESTORATIONS D0220 Intraoral - Periapical - First Film 19 D2510 Inlay - Metallic - One Surface 484 D0230 Intraoral - Periapical - Each Additional Film 16 D2520 Inlay - Metallic - Two Surfaces 575 D0240 Intraoral - Occlusal Film 29 D2530 Inlay - Metallic - Three Or More Surfaces 663 D0250 Extraoral - First Film 36 D2542 Onlay Metallic, Two Surfaces 624 D0260 Extraoral - Each Additional Film 33 D2543 Onlay-Metallic-Three Surfaces 679 D0270 Bitewing - Single Film 19 D2544 Onlay-Metallic-Four Or More Surfaces 707 D0272 Bitewings - Two Films 30 D2610 Inlay - Porcelain/Ceramic - One Surface 551 D0273 Bitewings - three films 37 D2620 Inlay - Porcelain/Ceramic - Two Surfaces 629 D0274 Bitewings - Four Films 42 D2630 Inlay - Porcelain/Ceramic - Three Or More Surfaces 670 D0277 Vertical Bitewings, 7-8 Films 64 D2642 Onlay - Porcelain/Ceramic - Two Surfaces 651 D0330 Panoramic Film 76 D2643 Onlay - Porcelain/Ceramic - Three Surfaces 702 D0340 Cephalometric Film 86 D2644 Onlay - Porcelain/Ceramic - Four Or More Surfaces 745 D0350 Oral/Facial Images (Includes Intra And Extraoral Image 41 D2650 Inlay - Composite/Resin - One Surface 428 D0415 Bacteriologic Studies For Determination Of Pathologic 25 D2651 Inlay - Composite/Resin - Two Surfaces 467 D0425 Caries Susceptibility Tests 21 D2652 Inlay - Composite/Resin - Three Or More Surfaces 491 D0431 Diag tst detect mucos abnorm 33 D2662 Onlay - Composite/Resin - Two Surfaces 426 D0460 Pulp Vitality Tests 34 D2663 Onlay - Composite/Resin - Three Surfaces 501 D0470 Diagnostic Casts 74 D2664 Onlay - Composite/Resin - Four Or More Surfaces 537 D0486 Accession of brush biopsy 80 D2699A D0999A Max Fee Max Fee 0 0 0 0 D2710 CROWNS-SINGLE RESTORATIONS ONLY 0 D2710 Crown - Resin (Laboratory) 305 Prophylaxis - Adult 60 D2712 Crown 3/4 resin-based compos 305 Prophylaxis - Child 45 D2720 Crown - Resin With High Noble Metal 706 D1206 Topical fluoride varnish 32 D2721 Crown - Resin With Predominantly Base Metal 661 D1208 Topical Application Of Fluoride 24 D2722 Crown - Resin With Noble Metal 676 D1351 Sealant - Per Tooth 37 D2740 Crown - Porcelain/Ceramic Substrate 759 D1352 preventive resin restoration in a moderate to high caries 36 D2750 Crown - Porcelain Fused To High Noble Metal 715 D1510 Space Maintainer - Fixed - Unilateral 224 D2751 Crown - Porcelain Fused To Predominantly Base Metal 666 D1515 Space Maintainer - Fixed - Bilateral 313 D2752 Crown - Porcelain Fused To Noble Metal 686 D1520 Space Maintainer - Removable - Unilateral 246 D2780 Crown, 3/4 Cast High Noble Metal 686 D1525 Space Maintainer - Removable - Bilateral 377 D2781 Crown, 3/4 Cast Predominately Base Metal 646 D1550 Recementation Of Space Maintainer 48 D2782 Crown, 3/4 Cast Noble Metal 666 D1555 Remove fix space maintainer 47 D2783 Crown, 3/4 Porcelain/Ceramic 705 0 D2790 Crown - Full Cast High Noble Metal 690 0 D2791 Crown - Full Cast Predominantly Base Metal 654 D1000 PREVENTIVE SERVICES D1110 D1120 D1999A 0 D2000 BASIC RESTORATIONS D2140 Amalgam - One Surface, Permanent 84 D2792 Crown - Full Cast Noble Metal 666 D2150 Amalgam - Two Surfaces, Permanent 103 D2794 Crown-titanium 706 D2160 Amalgam - Three Surfaces, Permanent 122 D2799 Provisional Crown 287 D2161 Amalgam - Four Or More Surfaces, Permanent 152 D2799A CDFS RMG00000 0 1 Connection Dental PPO Fee Schedule Proc Code Procedure Description D2910 OTHER RESTORATIVE SERVICES D2910 Recement Inlay D2915 Recement cast or prefab post D2920 Recement Crown D2929 Max Fee Proc Code Procedure Description Max Fee 0 D3410 Apicoectomy/Periradicular Surgery - Anterior 491 65 D3421 Apicoectomy/Periradicular Surgery - Bicuspid (First Roo 546 65 D3425 Apicoectomy/Periradicular Surgery - Molar (First Root) 619 67 D3426 Apicoectomy/Periradicular Surgery (Each Additional Ro 209 Prefabricated Porcelain/Ceramic Crown Primary Tooth 182 D3427 Periradicular surgery without apicoectomy 393 D2930 Prefabricated Stainless Steel Crown - Primary Tooth 182 D3430 Retrograde Filling - Per Root 154 D2931 Prefabricated Stainless Steel Crown - Permanent Tooth 202 D3450 Root Amputation - Per Root 320 D2932 Prefabricated Resin Crown 225 D3920 Hemisection (Including Any Root Removal), Not Includi 243 D2933 Prefabricated Stainless Steel Crown With Resin Windo 244 D3999A D2934 Prefab steel crown primary 247 D4000 PERIODONTIC SERVICES D2940 Sedative Filling D2950 Core Buildup, Including Any Pins D2951 Pin Retention - Per Tooth, In Addition To Restoration D2952 0 0 68 D4210 Gingivectomy Or Gingivoplasty - Per Quadrant 363 171 D4211 Gingivectomy Or Gingivoplasty, Per Tooth 163 40 D4212 Gingivectomy Or Gingivoplasty To Allow Access For Re Cast Post And Core In Addition To Crown 280 D4240 Gingival Flap Procedure, Including Root Planing - Per 467 D2953 Each Additional Cast Post, Same Tooth 140 D4241 Gingival Flap Procedure, Including Root Planing - One 270 D2954 Prefabricated Post And Core In Addition To Crown 215 D4245 Apically Positioned Flap 344 D2957 Each Additional Prefabricated Post, Same Tooth 112 D4249 Clinical Crown Lengthening - Hard Tissue 512 D2960 Labial Veneer (Laminate) - Chairside 427 D4260 Osseous Surgery (Including Flap Entry And Closure) - 778 D2961 Labial Veneer (Resin Laminate) - Laboratory 603 D4261 Osseous Surgery (Including Flap Entry And Closure) - 1 418 D2962 Labial Veneer (Porcelain Laminate) - Laboratory 668 D4263 Bone Replacement Graft - First Site In Quadrant 280 D2970 Temporary Crown (Fractured Tooth) 168 D4264 Bone Replacement Graft - Each Additional Site In Quad 238 D2971 Add proc construct new crown 103 D4265 Biologic Materials To Aid In Soft And Osseous Tissue R 114 D2975 Coping 321 D4266 Guided Tissue Regeneration - Resorbable Barrier, Per 287 D2980 Crown Repair, By Report 132 D4267 Guided Tissue Regeneration - Nonresorbable Barrier, P 369 D2981 Inlay Repair Necessitated By Restorative Material Failu 94 D4268 Surgical Revision Procedure, Per Tooth 483 D2982 Onlay Repair Necessitated By Restorative Material Fail 109 D4270 Pedicle Soft Tissue Graft Procedure 537 D2983 Veneer Repair Necessitated By Restorative Material Fa 100 D4273 Subepithelial Connective Tissue Graft Procedure (Inclu 676 D2990 Resin Infiltration Of Recipient Smooth Surface Lesions 32 D4274 Distal Or Proximal Wedge Procedure (When Not Perfor 379 0 D4275 Soft Tissue Allograft 508 0 D4276 Combined Connective Tissue And Double Pedicle Graft 758 D2999A 89 D3000 ENDODONTIC SERVICES D3110 Pulp Cap - Direct (Excluding Final Restoration) 52 D4277 Free Soft Tissue Graft Procedure Including Donor Site 574 D3120 Pulp Cap - Indirect (Excluding Final Restoration) 42 D4278 Free Soft Tissue Graft Procedure Including Donor Site 287 D3220 Therapeutic Pulpotomy (Excluding Final Restoration) 107 D4320 Provisional Splinting - Intracoronal 274 D3221 Gross Pulpal Debridement, Primary And Permanent Te 117 D4321 Provisional Splinting - Extracoronal 246 D3222 Part pulp for apexogenesis 110 D4341 Periodontal Scaling And Root Planing, Per Quadrant 161 D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary 122 D4342 Periodontal Scaling And Root Planing - One - Three Te 109 D3240 Pulpal Therapy (Resorbable Filling) - Posterior, Primary 151 D4355 Full Mouth Debridement To Enable Comprehensive Per 110 D3310 Root Canal Therapy - Anterior (Excluding Final Restora 479 D4381 Localized Delivery Of Chemotherapeutic Agents Via A 38 D3320 Root Canal Therapy - Bicuspid (Excluding Final Restor 587 D4910 Periodontal Maintenance Procedures (Following Active 90 D3330 Root Canal Therapy - Molar (Excluding Final Restoratio 728 D4920 Unscheduled Dressing Change (By Someone Other Th 62 D3332 Incomplete Endodontic Therapy, Inoperable Or Fractur 302 D4999A D3346 Retreatment Of Previous Root Canal Therapy - Anterior 638 D5000 PROSTHODONTICS-REMOVABLE D3347 Retreatment Of Previous Root Canal Therapy - Bicuspi 751 D5110 Complete Denture - Maxillary 821 D3348 Retreatment Of Previous Root Canal Therapy - Molar 930 D5120 Complete Denture - Mandibular 821 D3351 Apexification/Recalcification - Initial Visit (Apical Closur 248 D5130 Immediate Denture - Maxillary 895 D3352 Apexification/Recalcification - Interim Medication Repla 111 D5140 Immediate Denture - Mandibular 895 D3353 Apexification/Recalcification - Final Visit (Includes Com 341 D5211 Maxillary Partial Denture - Resin Base (Including Any C 692 D3355 Pulpal regeneration - initial visit 248 D5212 Mandibular Partial Denture - Resin Base (Including Any 771 D3356 Pulpal regeneration - interim medication replacement 111 D5213 Maxillary Partial Denture - Cast Metal Framework With 907 D3357 Pulpal regeneration - completion of treatment 341 D5214 Mandibular Partial Denture - Cast Metal Framework Wit 907 CDFS RMG00000 0 0 2 Connection Dental PPO Fee Schedule Proc Code Procedure Description D5225 Maxillary part denture flex D5226 Mandibular part denture flex D5281 Removable Unilateral Partial Denture - One Piece Cast D5410 Adjust Complete Denture - Maxillary D5411 Proc Code Procedure Description 805 D6067 Implant Supported Metal Crown 734 805 D6068 Abutment Supported Retainer For Porcelain/Ceramic F 783 529 D6069 Abutment Supported Retainer For Porcelain Fused To 779 45 D6070 Abutment Supported Retainer For Porcelain Fused To 736 Adjust Complete Denture - Mandibular 45 D6071 Abutment Supported Retainer For Porcelain Fused To 751 D5421 Adjust Partial Denture - Maxillary 45 D6072 Abutment Supported Retainer For Cast Metal Fpd (High 750 D5422 Adjust Partial Denture - Mandibular 47 D6073 Abutment Supported Retainer For Cast Metal Fpd (Pre 695 D5510 Repair Broken Complete Denture Base 90 D6074 Abutment Supported Retainer For Cast Metal Fpd (Nobl 738 D5520 Replace Missing Or Broken Teeth - Complete Denture ( 75 D6075 Implant Supported Retainer For Ceramic Fpd 777 D5610 Repair Resin Denture Base 97 D6076 Implant Supported Retainer For Porcelain Fused To Me 785 D5620 Repair Cast Framework 105 D6077 Implant Supported Retainer For Case Metal Fpd 734 D5630 Repair Or Replace Broken Clasp 127 D6080 Implant Maintenance Procedures, Including: Removal D5640 Replace Broken Teeth - Per Tooth 82 D6091 Repl semi/precision attach D5650 Add Tooth To Existing Partial Denture 112 D6092 Recement supp crown D5660 Add Clasp To Existing Partial Denture 135 D6093 Recement supp part denture 83 D5670 Replace All Teeth And Acrylic On Cast Metal Framewor 330 D6094 Abut support crown titanium 618 D5671 Replace All Teeth And Acrylic On Cast Metal Framewor 330 D6095 Repair Implant Abutment, By Report 425 D5710 Rebase Complete Maxillary Denture 334 D6100 Implant Removal, By Report 535 D5711 Rebase Complete Mandibular Denture 319 D6110 Implant abutment supported removable denture for ede 1024 D5720 Rebase Maxillary Partial Denture 315 D6111 Implant abutment supported removable denture for ede 1024 D5721 Rebase Mandibular Partial Denture 315 D6112 Implant abutment supported removable denture for parti 1024 D5730 Reline Complete Maxillary Denture (Chairside) 188 D6113 Implant abutment supported removable denture for part 413 D5731 Reline Complete Mandibular Denture (Chairside) 188 D6114 Implant abutment supported fixed denture for edentilou 2088 D5740 Reline Maxillary Partial Denture (Chairside) 173 D6115 Implant abutment supported fixed denture for edentilou 2088 D5741 Reline Mandibular Partial Denture (Chairside) 173 D6116 Implant abutment supported fixed denture for edentilou 1800 D5750 Reline Complete Maxillary Denture (Laboratory) 251 D6117 Implant abutment supported fixed denture for edentilou 1800 D5751 Reline Complete Mandibular Denture (Laboratory) 251 D6190 Radio/surgical implant index 139 D5760 Reline Maxillary Partial Denture (Laboratory) 247 D6194 Abut support retainer titani 637 D5761 Reline Mandibular Partial Denture (Laboratory) 247 D6199A D5850 Tissue Conditioning, Maxillary 86 D6200 PROSTHODONTICS-FIXED D5851 Tissue Conditioning, Mandibular 79 D6205 Pontic-indirect resin based 465 D5875 Modification Of Removable Prosthesis Following Implan 44 D6210 Pontic - Cast High Noble Metal 711 D5992 Adjust Maxillofacial Prosthetic Appliance By Report 103 D6211 Pontic - Cast Predominantly Base Metal 666 D5993 Extra Or Intraoral Other Than Required Adjustments By 103 D6212 Pontic - Cast Noble Metal 693 0 D6214 Pontic titanium 715 0 D6240 Pontic - Porcelain Fused To High Noble Metal 702 D5999A Max Fee Max Fee 65 315 61 0 0 D6000 IMPLANT SERVICES D6010 Surgical Placement Of Implant Body: Endosteal Implant 1372 D6241 Pontic - Porcelain Fused To Predominantly Base Metal 648 D6050 Surgical Placement: Transosteal Implant 3521 D6242 Pontic - Porcelain Fused To Noble Metal 684 D6055 Dental Implant Supported Connecting Bar 413 D6245 Pontic-Porcelain/Ceramic 724 D6056 Prefabricated Abutment 305 D6250 Pontic - Resin With High Noble Metal 693 D6057 Custom Abutment 363 D6251 Pontic - Resin With Predominantly Base Metal 543 D6058 Abutment Supported Porcelain/Ceramic Crown 792 D6252 Pontic - Resin With Noble Metal 659 D6059 Abutment Supported Porcelain Fused To Metal Crown ( 813 D6545 Retainer - Cast Metal For Resin Bonded Fixed Prosthes 271 D6060 Abutment Supported Porcelain Fused To Metal Crown ( 736 D6548 Retainer-Porcelain/Ceramic For Resin Bonded Fixed Pr 346 D6061 Abutment Supported Porcelain Fused To Metal Crown ( 760 D6549 resin retainer - for resin bonded fixed prosthesis 346 D6062 Abutment Supported Cast Metal Crown (High Noble Me 748 D6600 Inlay-Porcelain/Ceramic, Two Surfaces 518 D6063 Abutment Supported Cast Metal Crown (Predominately 689 D6601 Inlay - Porcelain/Ceramic, Three Or More Surfaces 391 D6064 Abutment Supported Cast Metal Crown (Noble Metal) 725 D6602 Inlay - Cast High Noble Metal, Two Surfaces 400 D6065 Implant Supported Porcelain/Ceramic Crown 777 D6603 Inlay - Cast High Noble Metal, Three Or More Surfaces 609 D6066 Implant Supported Porcelain Fused To Metal Crown 757 D6604 Inlay - Cast Predominantly Base Metal, Two Surfaces 542 CDFS RMG00000 3 Connection Dental PPO Fee Schedule Proc Code Procedure Description D6605 Inlay - Cast Predominantly Base Metal, Three Or More D6606 Inlay - Cast Noble Metal, Two Surfaces D6607 D6608 Proc Code Procedure Description 575 D7285 Biopsy Of Oral Tissue - Hard (Bone, Tooth) 483 403 D7286 Biopsy Of Oral Tissue - Soft (All Others) 275 Inlay - Cast Noble Metal, Three Or More Surfaces 592 D7288 Brush biopsy 110 Onlay - Porcelain/Ceramic, Two Surfaces 427 D7290 Surgical Repositioning Of Teeth 276 D6609 Onlay - Porcelain/Ceramic, Three Or More Surfaces 587 D7292 Screw retained plate 441 D6610 Onlay - Cast High Noble Metal, Two Surfaces 596 D7293 Temp anchorage dev w flap 276 D6611 Onlay - Cast High Noble Metal, Three Or More Surface 653 D7294 Temp anchorage dev w/o flap 230 D6612 Onlay - Cast Predominantly Base Metal, Two Surfaces 594 D7310 Alveoloplasty In Conjunction With Extractions - Per Qua 187 D6613 Onlay - Cast Predominantly Base Metal, Three Or More 620 D7311 Alveoloplasty w/extract 1-3 162 D6614 Onlay - Cast Noble Metal, Two Surfaces 581 D7320 Alveoloplasty Not In Conjunction With Extractions - Per 297 D6615 Onlay - Cast Noble Metal, Three Or More Surfaces 604 D7321 Alveoloplasty not w/extracts 257 D6624 Inlay titanium 553 D7410 Radical Excision - Lesion Diameter Up To 1.25 Cm 446 D6634 Onlay titanium 581 D7450 Removal Of Odontogenic Cyst Or Tumor - Lesion Diam 475 D6710 Crown-indirect resin based 547 D7451 Removal Of Odontogenic Cyst Or Tumor - Lesion Diam 768 D6720 Crown - Resin With High Noble Metal 691 D7460 Removal Of Nonodontogenic Cyst Or Tumor - Lesion Di 458 D6721 Crown - Resin With Predominantly Base Metal 656 D7471 Removal Of Exostotis-Per Site 623 D6722 Crown - Resin With Noble Metal 668 D7472 Removal Of Torus Palatinus 683 D6740 Crown-Porcelain/Ceramic 727 D7473 Removal Of Torus Mandibularis 681 D6750 Crown - Porcelain Fused To High Noble Metal 708 D7485 Surgical Reduction Of Osseous Tuberosity 589 D6751 Crown - Porcelain Fused To Predominantly Base Metal 660 D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissu 192 D6752 Crown - Porcelain Fused To Noble Metal 676 D7511 Incision/drain abscess intra 267 D6780 Crown - 3/4 Cast High Noble Metal 668 D7530 Removal Of Foreign Body, Skin, Or Subcutaneous Areo 311 D6781 Crown-3/4 Cast Predominately Based Metal 668 D7880 Occlusal Orthotic Device, By Report 505 D6782 Crown-3/4 Cast Noble Metal 620 D7910 Suture Of Recent Small Wounds Up To 5 Cm 262 D6783 Crown-3/4 Porcelain/Ceramic 688 D7911 Complicated Suture - Up To 5 Cm D6790 Crown - Full Cast High Noble Metal 684 D7912 Complicated Suture - Greater Than 5 Cm D6791 Crown - Full Cast Predominantly Base Metal 648 D7921 collection and application of autologous blood concentr 261 D6792 Crown - Full Cast Noble Metal 671 D7960 Frenulectomy (Frenectomy Or Frenotomy) - Separate P 282 D6794 Crown titanium 671 D7963 Frenuloplasty 334 D6920 Connector Bar 148 D7970 Excision Of Hyperplastic Tissue - Per Arch 376 D6930 Recement Fixed Partial Denture 86 D7971 Excision Of Pericoronal Gingiva 146 D6940 Stress Breaker 195 D7972 Surgical Reduction Of Fibrous Tuberosity 448 D6950 Precision Attachment 376 D7999A D6980 Fixed Partial Denture Repair, By Report 153 D8000 ORTHODONTIC SERVICES 0 D8010 Limited Orthodontic Treatment Of The Primary Dentition 1200 0 D8020 Limited Orthodontic Treatment Of The Transitional Dent 1200 D6999A Max Fee Max Fee 577 1746 0 0 D7000 ORAL SURGERY D7111 Coronal Remnants - Deciduous Tooth 75 D8030 Limited Orthodontic Treatment Of The Adolescent Denti 1200 D7140 Extraction, Erupted Tooth Or Exposed Root (Elevation 99 D8040 Limited Orthodontic Treatment Of The Adult Dentition 1200 D7210 Surgical Removal Of Erupted Tooth Requiring Elevation 176 D8050 Interceptive Orthodontic Treatment Of The Primary Den 1500 D7220 Removal Of Impacted Tooth - Soft Tissue 220 D8060 Interceptive Orthodontic Treatment Of The Transitional 1500 D7230 Removal Of Impacted Tooth - Partially Bony 289 D8070 Comprehensive Orthodontic Treatment Of The Transitio 3800 D7240 Removal Of Impacted Tooth - Completely Bony 343 D8080 Comprehensive Orthodontic Treatment Of The Adolesc 3800 D7241 Removal Of Impacted Tooth - Completely Bony, With U 434 D8090 Comprehensive Orthodontic Treatment Of The Adult De 3800 D7250 Surgical Removal Of Residual Tooth Roots (Cutting Pro 187 D8210 Removable Appliance Therapy 550 D7251 Coronectomy - Intentional Partial Tooth Removal 187 D8220 Fixed Appliance Therapy 550 D7260 Oroantral Fistula Closure 882 D8680 Orthodontic Retention (Removal Of Appliances, Constr 350 D7261 Primary Closure Of A Sinus Perforation 459 D8999A D7270 Tooth Reimplantation And/Or Stabilization Of Accidenta 344 D9000 ADJUNCTIVE GENERAL SERVICES D7280 Surgical Exposure Of Impacted Or Unerupted Tooth Fo 321 D9110 Palliative (Emergency) Treatment Of Dental Pain - Mino D7283 Place device impacted tooth 138 D9220 General Anesthesia - First 30 Minutes CDFS RMG00000 0 0 70 264 4 Connection Dental PPO Fee Schedule Proc Code Procedure Description D9221 General Anesthesia - Each Additional 15 Minutes 118 D9241 Intravenous Sedation/Analgesia, First 30 Minutes 205 D9242 Intravenous Sedation/Analgesia, Each Additional Fiftee 100 D9310 Consultation (Diagnostic Service Provided By Dentist O 80 D9440 Office Visit - After Regularly Scheduled Hours 50 D9610 Therapeutic Drug Injection, By Report 23 D9612 Thera par drugs 2 or > admin 23 D9910 Application Of Desensitizing Medicament 32 D9911 Application Of Desensitizing Resin For Cervical And/Or D9940 Occlusal Guard, By Report D9941 Fabrication Of Athletic Mouthguard 92 D9950 Occlusion Analysis - Mounted Case 161 D9951 Occlusal Adjustment - Limited D9952 Occlusal Adjustment - Complete 329 D9972 External Bleaching-Per Arch 163 D9973 External Bleaching-Per Tooth 44 D9974 Internal Bleaching-Per Tooth 148 D9999A Max Fee Proc Code Procedure Description Max Fee 41 255 71 0 Orthodontics - Comprehensive Case Active Treatment Phase - begins when the bands are first placed on the teeth and ends after 24 consecutive months or the bands are removed from the teeth, whichever occurs first. CDFS RMG00000 5
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