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Confidential Filed Fee Schedule


									                                                                                                         Provider File
                                                                                        License # _________________________________

                                                                                        Name ____________________________________

                                                                                        Effective Date: ________________________, 20__
        Delta Dental of Nebraska
        For processing send to:                                                         Enter Date: ___________________________, 20__
        P. O. Box 9304
        Minneapolis, MN 55440-9304                                                      Operator: _________________________________

                                                                                        Notes: ____________________________________

Confidential Filed Fee Schedule                                                                        For Delta Use Only

(Updated to include CDT 2007 code terminology)

Statement of Intent:

I agree that each fee submitted to Delta Dental on a claim for dental services I provide to any Delta Dental patient will be
these pre-filed fees or the fees actually charged and accepted as payment in full, whichever is less, consistent with the
rules and regulations of Delta Dental. If requested by Delta Dental, I will verify by providing documentary evidence
satisfactory to Delta Dental that the fees listed on this schedule are my normal (most frequently charged) fees for dental
procedures uniformly charged to patients or third party payors. I understand that I cannot revise my pre-filed fees until
after the expiration of six (6) months from the effective date indicated below.


                Fees must be filed with Delta Dental 30 days prior to their effective date to ensure proper payment of
                claims. Fee ranges per procedure are not accepted. Please retain a copy of this form with your records.

                These new fees are effective on __________________________________________, 20____

Dentist Information: To ensure an accurate update, ALL dentists and ALL locations must be given.

This fee schedule applies to the following dentist(s) at the following locations(s) ONLY. Please attach additional sheets if necessary.

________________________________       _______________________________         _______________     ______     __________________________
     Dentist Personal Signature               Dentist Name (print)              License Number      State       Tax Identification Number

_____________________________________________________                          ___________________            ________       __________
                              Street Address                                              City                   State             Zip
________________________________       _______________________________         _______________     ______     __________________________
     Dentist Personal Signature               Dentist Name (print)              License Number      State       Tax Identification Number

_____________________________________________________                          ___________________           _________       __________
                              Street Address                                              City                   State             Zip
________________________________       _______________________________         _______________     ______     __________________________
     Dentist Personal Signature               Dentist Name (print)              License Number      State       Tax Identification Number

_____________________________________________________                          ___________________           _________       __________
                              Street Address                                              City                   State             Zip
________________________________       _______________________________         ______________      ______      _______________________
     Dentist Personal Signature               Dentist Name (print)             License Number       State      Tax Identification Number

_____________________________________________________                          ___________________            ________       __________
                              Street Address                                              City                   State             Zip
________________________________       _______________________________         _______________     ______     __________________________
     Dentist Personal Signature               Dentist Name (print)              License Number      State       Tax Identification Number

_____________________________________________________                          ___________________            ________        _________
                              Street Address                                              City                   State             Zip

November 2006                                                  Page 1
                                              D0421 Genetic test for susceptibility to   $   D1206 Topical fluoride varnish;            $
                                                    oral diseases                                  therapeutic application for
D0120 Periodic oral evaluation -          $                                                        moderate to high caries risk
                                              D0425 Caries susceptibility tests          $
      established patient                                                                          patients
                                              D0431 Adjunctive pre-diagnostic test       $
D0140 Limited oral evaluation - problem $                                                    D1310 Nutritional counseling for control   $
                                                    that aids in detection of mucosal
      focused                                                                                      of dental disease
                                                    abnormalities including
D0145 Oral evaluation for a patient       $         premalignant and malignant               D1320 Tobacco counseling for the           $
      under three years of age and                  lesions, not to include cytology               control and prevention of oral
      counseling with primary                       or biopsy procedures                           disease
                                              D0460 Pulp vitality tests                  $   D1330 Oral hygiene instructions            $
D0150 Comprehensive oral evaluation -     $
                                              D0470 Diagnostic casts                     $   D1351 Sealant - per tooth                  $
      new or established patient
                                              D0472 Accession of tissue, gross           $
D0160 Detailed and extensive oral         $                                                  IV. SPACE MAINTENANCE (Passive Appliances)
                                                    examination, preparation and
      evaluation - problem focused
                                                    transmission of written report           D1510 Space maintainer - fixed-            $
D0170 Re-evaluation - limited, problem $                                                           unilateral
                                              D0473 Accession of tissue, gross and       $
      focused (established patient; not
                                                    microscopic examination,                 D1515 Space maintainer - fixed -           $
      post-operative visit)
                                                    preparation and transmission of                bilateral
D0180 Comprehensive periodontal           $         written report
                                                                                             D1520 Space maintainer - removable -       $
      evaluation - new or established
                                              D0474 Accession of tissue, gross and       $         unilateral
                                                    microscopic examination,
                                                    including assessment of surgical         D1525 Space maintainer - removable -       $
II. RADIOGRAPHS/DIAGNOSTIC IMAGING                                                                 bilateral
                                                    margins for presence of disease,
D0210 Intraoral - complete series         $         preparation and transmission of          D1550 Re-cementation of space              $
      (including bitewings)                         written report                                 maintainer
D0220 Intraoral - periapical first film   $   D0475 Decalcification procedure            $   D1555 Removal of fixed space               $
                                              D0476 Special stains for                   $         maintainer
D0230 Intraoral - periapical each         $
      additional film                               microorganisms
                                                                                              AMALGAM RESTORATIONS
D0240 Intraoral - occlusal film           $   D0477 Special stains, not for              $
                                                    microorganisms                           D2140 Amalgam - one surface, primary       $
D0250 Extraoral - first film              $                                                        or permanent
                                              D0478 Immunohistochemical stains           $
D0260 Extraoral - each additional film    $                                                  D2150 Amalgam - two surfaces, primary $
                                              D0479 Tissue in-situ hybridization,        $         or permanent
D0270 Bitewing - single film              $         including interpretation
                                                                                             D2160 Amalgam - three surfaces,            $
D0272 Bitewings - two films               $   D0480 Accession of exfoliative cytologic   $         primary or permanent
D0273 Bitewings - three films             $         smears, microscopic
                                                    examination, preparation and             D2161 Amalgam - four or more               $
D0274 Bitewings - four films              $         transmission of written report                 surfaces, primary or permanent
D0277 Vertical bitewings - 7 to 8 films   $   D0481 Electron microscopy- diagnostic      $   VI. RESIN – BASED COMPOSITE RESTORATIONS
D0290 Posterior - anterior or lateral     $   D0482 Direct immunofluorescence            $   D2330 Resin - based composite - one        $
      skull & facial bone survey film
                                              D0483 Indirect immunofluorescence          $         surface, anterior
D0310 Sialography                         $
                                              D0484 Consultation on slides prepared      $   D2331 Resin - based composite - two        $
D0320 Temporomandibular joint             $         elsewhere                                      surfaces, anterior
      arthrogram, including injection
                                              D0485 Consultation including            $      D2332 Resin - based composite - three      $
D0321 Other temporomandibular joint       $         preparation of slides from biopsy              surfaces, anterior
      films, by report                              material supplied by referring           D2335 Resin - based composite - four       $
                                                    source                                         or more surfaces or involving
D0322 Tomographic survey                  $
                                              D0486 Accession of brush biopsy            $         incisal angle, (anterior)
D0330 Panoramic film                      $
                                                    sample, microscopic                      D2390 Resin - based composite crown,       $
D0340 Cephalometric film                  $         examination, preparation and                   anterior
                                                    transmission of written report
D0350 Oral/facial photographic images     $                                                  D2391 Resin - based composite - one        $
                                              D0502 Other oral pathology procedures, $             surface, posterior
D0360 Cone beam ct - craniofacial data    $
                                                    by report
      capture                                                                                D2392 Resin - based composite - two        $
                                              D0999 Unspecified diagnostic               $
D0362 Cone beam - two-dimensional         $                                                        surfaces, posterior
                                                    procedures, by report
      image reconstruction using                                                             D2393 Resin - based composite - three      $
      existing data, includes multiple        III. PREVENTIVE SERVICES                             surfaces, posterior
                                              D1110 Prophylaxis - adult                  $   D2394 Resin based composite – four or      $
D0363 Cone beam - three-dimensional       $                                                        more surfaces, posterior
      image reconstruction using              D1120 Prophylaxis - child                  $
      existing data, includes multiple        D1203 Topical application of fluoride    $     VII. GOLD FOIL RESTORATIONS
      images                                        (prophylaxis not included) - child
                                                                                             D2410 Gold foil - one surface              $
D0415 Collection of microorganisms for    $   D1204 Topical application of fluoride      $
      culture and sensitivity                       (prophylaxis not included) -             D2420 Gold foil - two surfaces             $
D0416 Viral culture                       $         adult                                    D2430 Gold foil - three surfaces           $

  November 2006                                                     Page 2
                                              D2790 Crown - full cast high noble         $   D3220 Therapeutic pulpotomy                    $
                                                    metal                                          (excluding final restoration)
D2510 Inlay - metallic - one surface      $                                                        removal of pulp coronal to the
                                              D2791 Crown - full cast predominantly      $
                                                                                                   dentinocemental junction and
D2520 Inlay - metallic - two surfaces     $         base metal
                                                                                                   application of medicament
D2530 Inlay - metallic - three or more    $   D2792 Crown - full cast noble metal        $
                                                                                             D3221 Pulpal debridement, primary and $
      surfaces                                                                                     permanent teeth
                                              D2794 Crown - titanium                     $
D2542 Onlay - metallic - two surfaces     $                                                  D3230 Pulpal therapy (resorbable               $
                                              D2799 Provisional crown                    $
D2543 Onlay - metallic - three surfaces   $                                                        filling) - anterior, primary tooth
                                              X. OTHER RESTORATIVE SERVICES                        (excluding final restoration)
D2544 Onlay - metallic, four or more      $
      surfaces                                D2910 Recement inlay, onlay, or partial    $   D3240 Pulpal therapy (resorbable          $
                                                    coverage restoration                           filling) - posterior, primary tooth
D2610 Inlay - porcelain/ceramic - one     $                                                        (excluding final restoration)
      surface                                 D2915 Recement cast or prefabricated       $
                                                    post and core                            D3310 Anterior (excluding final                $
D2620 Inlay - porcelain/ceramic - two     $                                                        restoration)
      surfaces                                D2920 Recement crown                       $
                                                                                             D3320 Bicuspid (excluding final                $
D2630 Inlay - porcelain/ceramic - three   $   D2930 Prefabricated stainless steel        $         restoration)
      or more surfaces                              crown - primary tooth
                                                                                             D3330 Molar (excluding final                   $
D2642 Onlay - porcelain/ceramic - two     $   D2931 Prefabricated stainless steel        $         restoration)
      surfaces                                      crown – permanent tooth
                                                                                             D3331 Treatment of root canal                  $
D2643 Onlay - porcelain/ceramic - three $     D2932 Prefabricated resin crown            $         obstruction; non-surgical access
                                              D2933 Prefabricated stainless steel        $   D3332 Incomplete endodontic therapy;           $
D2644 Onlay - porcelain/ceramic - four    $         crown with resin window                        inoperable, unrestorable or
      or more surfaces                                                                             fractured tooth
                                              D2934 Prefabricated esthetic coated        $
D2650 Inlay - resin based composite -     $         stainless steel crown – primary          D3333 Internal root repair of                  $
      one surface                                   tooth                                          perforation defects
D2651 Inlay - resin based composite -     $   D2940 Sedative filling                     $   D3346 Retreatment of previous root             $
      two surfaces                                                                                 canal therapy - anterior
                                              D2950 Core buildup, including any pins     $
D2652 Inlay - resin based composite -     $                                                  D3347 Retreatment of previous root             $
                                              D2951 Pin retention - per tooth in         $
      three or more surfaces                                                                       canal therapy - bicuspid
                                                    addition to restoration
D2662 Onlay - resin based composite -     $                                                  D3348 Retreatment of previous root             $
                                              D2952 Cast post and core in addition to    $
      two surfaces                                                                                 canal therapy - molar
                                                    crown, indirectly fabricated
D2663 Onlay - resin based composite -     $                                                  D3351 Apexification/recalcification -          $
                                              D2953 Each additional indirectly           $
      three surfaces                                                                               initial visit (apical closure/calcific
                                                    fabricated post - same tooth
D2664 Onlay - resin based composite -     $                                                        repair of perforations, root
      four or more surfaces                   D2954 Prefabricated post and core in       $         resorption etc.)
                                                    addition to crown
                                                                                             D3352 Apexification/recalcification -          $
IX. CROWNS – SINGLE RESTORATIONS              D2955 Post removal (not in conjunction     $         interim medication replacement
                                                    with endodontic therapy)                       (apical closure /calcific repair of
D2710 Crown - resin - based composite     $
                                                                                                   perforations, root resorption,
      (indirect)                              D2957 Each additional prefabricated        $
                                                    post - same tooth
D2712 Crown - 3/4 resin based             $
                                                                                             D3353 Apexification/recalcification -          $
      composite (indirect)                    D2960 Labial veneer (resin laminate) -     $
                                                                                                   final visit (includes completed
D2720 Crown - resin with high noble       $                                                        root canal therapy - apical
      metal                                   D2961 Labial veneer (resin laminate) -     $         closure/calcific repair of
                                                    laboratory                                     perforations, root resorption,
D2721 Crown - resin with                  $
      predominantly base metal                D2962 Labial veneer (porcelain             $
                                                    laminate) - laboratory                   D3410 Apicoectomy/periradicular                $
D2722 Crown - resin with noble metal      $
                                                                                                   surgery - anterior
                                              D2970 Temporary crown (fractured           $
D2740 Crown - porcelain/ceramic           $
                                                    tooth)                                   D3421 Apicoectomy/periradicular                $
                                                                                                   surgery - bicuspid (first root)
                                              D2971 Additional procedures to             $
D2750 Crown - porcelain fused to high     $
                                                    construct new crown under                D3425 Apicoectomy/periradicular                $
      noble metal
                                                    existing partial denture                       surgery - molar (first root)
D2751 Crown - porcelain fused to          $         framework
                                                                                             D3426 Apicoectomy/periradicular                $
      predominantly base metal
                                              D2975 Coping                               $         surgery (each additional root)
D2752 Crown - porcelain fused to noble    $
                                              D2980 Crown repair, by report              $   D3430 Retrograde filling - per root            $
                                              D2999 Unspecified restorative              $   D3450 Root amputation - per root               $
D2780 Crown - 3/4 cast high noble         $
                                                    procedure, by report
      metal                                                                                  D3460 Endodontic endosseous implant            $
D2781 Crown - 3/4 cast predominantly      $   XI. ENDODONTICS                                D3470 Intentional reimplantation               $
      base metal                                                                                   (including necessary splinting)
                                              D3110 Pulp cap - direct (excluding final   $
D2782 Crown - 3/4 cast noble metal        $         restoration)                             D3910 Surgical procedure for isolation         $
                                                                                                   of tooth with rubber dam
D2783 Crown - 3/4 porcelain/ceramic       $   D3120 Pulp cap - indirect (excluding       $
                                                    final restoration)

November 2006                                                      Page 3
D3920 Hemisection (including any root     $   D4274 Distal/proximal wedge procedure $      D5281 Removable unilateral partial        $
      removal), not including root                  (when not performed in                       denture-– one piece cast metal
      canal therapy                                 conjunction with surgical                    (including clasps and teeth)
                                                    procedures in the same
D3950 Canal preparation and fitting of    $                                                D5410 Adjust complete denture -           $
                                                    anatomical area)
      preformed dowel or post                                                                    maxillary
                                              D4275 Soft tissue allograft              $
D3999 Unspecified endodontic              $                                                D5411 Adjust complete denture -           $
      procedure, by report                    D4276 Combined connective tissue and     $         mandibular
                                                    double pedicle graft, per tooth
                                                                                           D5421 Adjust partial denture - maxillary $
                                              D4320 Provisional splinting -            $
                                                                                           D5422 Adjust partial denture -            $
D4210 Gingivectomy or gingivoplasty -  $            intracoronal
      four or more contiguous teeth or
                                              D4321 Provisional splinting -            $
      bounded teeth spaces per                                                             D5510 Repair broken complete denture      $
      quadrant                                                                                   base
                                              D4341 Periodontal scaling and root       $
D4211 Gingivectomy or gingivoplasty -     $                                                D5520 Replace missing or broken teeth     $
                                                    planing - four or more teeth per
      one to three contiguous teeth or                                                           - complete denture (each tooth)
      bounded teeth spaces per
      quadrant                                                                             D5610 Repair resin denture base           $
                                              D4342 Periodontal scaling & root         $
                                                    planing – one to three teeth per       D5620 Repair cast framework               $
D4230 Anatomical crown exposure -         $
      four or more contiguous teeth                                                        D5630 Repair or replace broken clasp      $
      per quadrant                            D4355 Full mouth debridement to          $
                                                    enable comprehensive                   D5640 Replace broken teeth - per tooth $
D4231 Anatomical crown exposure -         $
                                                    evaluation and diagnosis               D5650 Add tooth to existing partial       $
      one to three teeth per quadrant
                                              D4381 Localized delivery of              $         denture
D4240 Gingival flap procedure,            $
                                                    antimicrobial agents via a             D5660 Add clasp to existing partial       $
      including root planing - four or
                                                    controlled release vehicle into              denture
      more contiguous teeth or
                                                    diseased crevicular tissue, per
      bounded teeth spaces per                                                             D5670 Replace all teeth and acrylic on    $
                                                    tooth, by report
      quadrant                                                                                   cast metal framework –
                                              D4910 Periodontal maintenance            $         (maxillary)
D4241 Gingival flap procedure,            $
      including root planning- one to         D4920 Unscheduled dressing change        $   D5671 Replace all teeth and acrylic on    $
      three contiguous teeth or                     (by someone other than treating              cast metal framework –
      bounded teeth spaces per                      dentist)                                     (mandibular)
                                              D4999 Unspecified periodontal            $   D5710 Rebase complete maxillary           $
D4245 Apically positioned flap            $         procedure, by report                         denture
D4249 Clinical crown lengthening - hard $                                                  D5711 Rebase complete mandibular          $
                                              XIII. PROSTHODONTICS (REMOVABLE)
      tissue                                                                                     denture
                                              D5110 Complete denture - maxillary       $
D4260 Osseous surgery (including flap   $                                                  D5720 Rebase maxillary partial denture    $
      entry and closure) - four or more       D5120 Complete denture - mandibular      $
      contiguous teeth or bounded                                                          D5721 Rebase mandibular partial           $
      teeth spaces per quadrant               D5130 Immediate denture - maxillary      $         denture

D4261 Osseous surgery (including flap     $   D5140 Immediate denture - mandibular     $   D5730 Reline complete maxillary           $
      entry and closure) - one to             D5211 Maxillary partial denture - resin $          denture (chairside)
      three contiguous teeth or                     base (including any conventional       D5731 Reline complete mandibular          $
      bounded teeth spaces per quad                 clasps, rests and teeth)                     denture (chairside)
D4263 Bone replacement graft - first      $   D5212 Mandibular partial denture -       $   D5740 Reline maxillary partial denture    $
      site in quadrant                              resin base (including any                    (chairside)
D4264 Bone replacement graft - each       $         conventional clasps, rests and
                                                    teeth)                                 D5741 Reline mandibular partial           $
      additional site in quadrant                                                                denture (chairside)
D4265 Biologic materials to aid in soft   $   D5213 Maxillary partial denture - cast   $
                                                    metal framework with resin             D5750 Reline complete maxillary partial   $
      and osseous tissue regeneration                                                            denture (laboratory)
                                                    denture bases (including any
D4266 Guided tissue regeneration -        $         conventional clasps, rests and         D5751 Reline complete mandibular          $
      resorbable barrier, per site                  teeth)                                       denture (laboratory)
D4267 Guided tissue regeneration -        $   D5214 Mandibular partial denture - cast $    D5760 Reline maxillary partial denture    $
      nonresorbable barrier, per site               metal framework with resin                   (laboratory)
      (includes membrane removal)                   denture bases (including any
                                                    conventional clasps, rests and         D5761 Reline mandibular partial           $
D4268 Surgical revision procedure, per    $                                                      denture (laboratory)
                                              D5225 Maxillary partial denture -        $   D5810 Interim complete denture            $
D4270 Pedicle soft tissue graft           $                                                      (maxillary)
                                                    flexible base (including any
                                                    conventional clasps, rests and         D5811 Interim complete denture            $
D4271 Free soft tissue graft procedure    $         teeth)                                       (mandibular)
      (including donor site surgery)
                                              D5226 Mandibular partial denture -       $   D5820 Interim partial denture             $
D4273 Subepithelial connective tissue     $         flexible base (including any                 (maxillary)
      graft procedures, per tooth                   conventional clasps, rests and
                                                    teeth)                                 D5821 Interim partial denture,            $
                                                                                           D5850 Tissue conditioning, maxillary      $

November 2006                                                      Page 4
D5851 Tissue conditioning, mandibular       $   D5983 Radiation carrier                   $   D6070 Abutment supported retainer for      $
                                                                                                    porcelain fused to metal FPD
D5860 Overdenture - complete, by            $   D5984 Radiation shield                    $
                                                                                                    (predominantly base metal)
                                                D5985 Radiation cone locator              $
                                                                                              D6071 Abutment supported retainer for      $
D5861 Overdenture - partial, by report      $
                                                D5986 Fluoride gel carrier                $         porcelain fused to metal FPD
D5862 Precision attachment, by report       $                                                       (noble metal)
                                                D5987 Commissure splint                   $
D5867 Replacement of replaceable part       $                                                 D6072 Abutment supported retainer for      $
                                                D5988 Surgical splint                     $         cast metal FPD (high noble
      of semi-precision or precision
      attachment (male or female                D5999 Unspecified maxillofacial           $         metal)
      component)                                      prosthesis, by report                   D6073 Abutment supported retainer for      $
D5875 Modification of removable             $                                                       cast metal FPD (predominantly
                                                XV.   IMPLANT SERVICES                              base metal)
      prosthesis following implant
      surgery                                   D6010 Surgical placement of implant       $   D6074 Abutment supported retainer for      $
D5899 Unspecified removable                 $         body: endosteal implant                       cast metal FPD (noble metal)
      prosthodontic procedure, by               D6012 Surgical placement of interim       $   D6075 Implant supported retainer for       $
      report                                          implant body for transitional                 ceramic FPD
                                                      prosthesis: endosteal implant
XIV. MAXILLOFACIAL PROSTHETICS                                                                D6076 Implant supported retainer for       $
                                                D6040 Surgical placement – eposteal       $         porcelain fused to metal FPD
D5911 Facial moulage (sectional)            $         implant                                       (titanium, titanium alloy, or high
D5912 Facial moulage (complete)             $   D6050 Surgical placement – transosteal    $         noble metal)
                                                      implant                                 D6077 Implant supported retainer for       $
D5913 Nasal prosthesis                      $
                                                D6053 Implant/abutment supported          $         cast metal FPD (titanium,
D5914 Auricular prosthesis                  $                                                       titanium alloy, or high noble
                                                      removable denture for
D5915 Orbital prosthesis                    $         completely edentulous arch                    metal)

D5916 Ocular prosthesis                     $   D6054 Implant/abutment supported          $   D6078 Implant/abutment supported           $
                                                      removable denture for partially               fixed denture for completely
D5919 Facial prosthesis                     $                                                       edentulous arch
                                                      edentulous arch
D5922 Nasal septal prosthesis               $                                                 D6079 Implant/abutment supported           $
                                                D6055 Dental implant supported            $
                                                      connecting bar                                fixed denture for partially
D5923 Ocular prosthesis, interim            $
                                                                                                    edentulous arch
D5924 Cranial prosthesis                    $   D6056 Prefabricated abutment -            $
                                                      includes placement                      D6080 Implant maintenance              $
D5925 Facial augmentation implant           $                                                       procedures, including removal of
      prosthesis                                D6057 Custom abutment - includes          $         prosthesis, cleansing of
                                                      placement                                     prosthesis and abutments and
D5926 Nasal prosthesis, replacement         $
                                                                                                    reinsertion of prosthesis
                                                D6058 Abutment supported                  $
D5927 Auricular prosthesis,                 $         porcelain/ceramic crown                 D6090 Repair implant supported             $
                                                                                                    prosthesis, by report
                                                D6059 Abutment supported porcelain     $
D5928 Orbital prosthesis, replacement       $         fused to metal crown (high noble        D6091 Replacement of semi-precision        $
D5929 Facial prosthesis, replacement        $         metal)                                        attachment (male or female
                                                                                                    component) of
D5931 Obturator prosthesis, surgical        $   D6060 Abutment supported porcelain        $
                                                                                                    implant/abutment supported
                                                      fused to metal crown
D5932 Obturator prosthesis, definitive      $                                                       prosthesis, per attachment
                                                      (predominantly base metal)
D5933 Obturator prosthesis,                 $                                                 D6092 Recement implant/abutment            $
                                                D6061 Abutment supported porcelain        $
      modification                                                                                  supported crown
                                                      fused to metal crown (noble
D5934 Mandibular resection prosthesis       $         metal)                                  D6093 Recement implant/abutment            $
      with guide flange                                                                             supported fixed partial denture
                                                D6062 Abutment supported cast metal       $
D5935 Mandibular resection prosthesis       $         crown (high noble metal)                D6094 Abutment supported crown             $
      without guide flange                                                                          (titanium)
                                                D6063 Abutment supported cast metal       $
D5936 Obturator prosthesis, interim         $         crown (predominantly base               D6095 Repair implant abutment, by          $
                                                      metal)                                        report
D5937 Trismus appliance (not for TMD        $
      treatment)                                D6064 Abutment supported cast metal       $   D6100 Implant removal, by report           $
                                                      crown (noble metal)
D5951 Feeding aid                           $                                                 D6190 Radiographic/surgical implant        $
                                                D6065 Implant supported                   $         index, by report
D5952 Speech aid prosthesis, pediatric      $         porcelain/ceramic crown
                                                                                              D6194 Abutment supported retainer          $
D5953 Speech aid prosthesis, adult          $   D6066 Implant supported porcelain         $         crown for FPD - (titanium)
                                                      fused to metal crown (titanium,
D5954 Palatal augmentation prosthesis       $                                                 D6199 Unspecified implant procedure,       $
                                                      titanium alloy, high noble metal)
D5955 Palatal lift prosthesis, definitive   $                                                       by report
                                                D6067 Implant supported metal crown       $
D5958 Palatal lift prosthesis, interim      $         (titanium, titanium alloy, high         XVI. PROSTHODONTICS, FIXED
                                                      noble metal)
D5959 Palatal lift prosthesis,              $                                                 D6205 Pontic - indirect resin based        $
      modification                              D6068 Abutment supported retainer for     $         composite
                                                      porcelain/ceramic FPD
D5960 Speech aid prosthesis,                $                                                 D6210 Pontic - cast high noble metal       $
      modification                              D6069 Abutment supported retainer for     $
                                                      porcelain fused to metal FPD            D6211 Pontic - cast predominantly base $
D5982 Surgical stent                        $                                                       metal
                                                      (high noble metal)

November 2006                                                        Page 5
D6212 Pontic - cast noble metal           $   D6722 Crown - resin with noble metal      $   D7240 Removal of impacted tooth -          $
                                                                                                  completely bony
D6214 Pontic - titanium                   $   D6740 Crown - porcelain/ceramic           $
                                                                                            D7241 Removal of impacted tooth -          $
D6240 Pontic - porcelain fused to high    $   D6750 Crown - porcelain fused to high     $
                                                                                                  completely bony, with unusual
      noble metal                                   noble metal
                                                                                                  surgical complications
D6241 Pontic - porcelain fused to         $   D6751 Crown - porcelain fused to          $
                                                                                            D7250 Surgical removal of residual         $
      predominantly base metal                      predominantly base metal
                                                                                                  tooth roots (cutting procedure)
D6242 Pontic - porcelain fused to noble   $   D6752 Crown - porcelain fused to noble    $
                                                                                            D7260 Oroantral fistula closure            $
      metal                                         metal
                                                                                            D7261 Primary closure of a sinus           $
D6245 Pontic - porcelain/ceramic          $   D6780 Crown - 3/4 cast high noble         $
D6250 Pontic - resin with high noble      $
                                                                                            D7270 Tooth reimplantation and/or          $
      metal                                   D6781 Crown - 3/4 cast predominantly      $
                                                                                                  stabilization of accidentally
                                                    based metal
D6251 Pontic - resin with predominantly $                                                         evulsed or displaced tooth
      base metal                              D6782 Crown - 3/4 cast noble metal        $
                                                                                            D7272 Tooth transplantation (includes      $
D6252 Pontic - resin with noble metal     $   D6783 Crown - 3/4 porcelain/ceramic       $         reimplantation from one site to
                                                                                                  another and splinting and/or
D6253 Provisional pontic                  $   D6790 Crown - full cast high noble        $         stabilization
D6545 Retainer - cast metal for resin     $                                                 D7280 Surgical access of an unerupted      $
      bonded fixed prosthesis                 D6791 Crown - full cast predominantly     $         tooth
                                                    base metal
D6548 Retainer - porcelain/ceramic for    $                                                 D7282 Mobilization of erupted or           $
      resin bonded fixed prosthesis           D6792 Crown - full cast noble metal       $         malpositioned tooth to aid
D6600 Inlay - porcelain/ceramic, two      $   D6793 Provisional retainer crown          $         eruption
      surfaces                                                                              D7283 Placement of device to facilitate    $
                                              D6794 Crown - titanium                    $
D6601 Inlay - porcelain/ceramic, three    $                                                       eruption of impacted tooth
                                              D6920 Connector bar                       $
      or more surfaces                                                                      D7285 Biopsy of oral tissue - hard         $
                                              D6930 Recement fixed partial denture      $         (bone, tooth)
D6602 Inlay - cast high noble metal,      $
      two surfaces                            D6940 Stress breaker                      $   D7286 Biopsy of oral tissue - soft         $
D6603 Inlay - cast high noble metal,      $   D6950 Precision attachment                $   D7287 Exfoliative cytological sample       $
      three or more surfaces                                                                      collection
                                              D6970 Post and core in addition to fixed $
D6604 Inlay - cast predominantly base     $         partial denture retainer,               D7288 Brush biopsy - transepithelial       $
      metal, two surfaces                           indirectly fabricated                         sample collection
D6605 Inlay - cast predominantly base     $   D6972 Prefabricated post and core in      $   D7290 Surgical repositioning of teeth      $
      metal, three or more surfaces                 addition to fixed partial denture
                                                    retainer                                D7291 Transseptal fiberotomy/supra         $
D6606 Inlay - cast noble metal, two       $                                                       crestal fiberotomy, by report
      surfaces                                D6973 Core build up for retainer,         $
                                                    including any pins                      D7292 Surgical placement: temporary        $
D6607 Inlay - cast noble metal, three or $                                                        anchorage device [screw
      more surfaces                           D6975 Coping - metal                      $         retained plate] requiring surgical
D6608 Onlay - porcelain/ceramic, two      $   D6976 Each additional indirectly          $         flap
      surfaces                                      fabricated post - same tooth            D7293 Surgical placement: temporary        $
D6609 Onlay - porcelain/ceramic, three    $   D6977 Each additional prefabricated       $         anchorage device requiring
      or more surfaces                              post - same tooth                             surgical flap

D6610 Onlay - cast high noble metal,      $   D6980 Fixed partial denture repair, by    $   D7294 Surgical placement: temporary        $
      two surfaces                                  report                                        anchorage device without
                                                                                                  surgical flap
D6611 Onlay - cast high noble metal,      $   D6985 Pediatric partial denture, fixed    $
      three or more surfaces                                                                D7310 Alveoloplasty in conjunction with $
                                              D6999 Unspecified fixed prosthodontic     $         extractions - four or more teeth
D6612 Onlay - cast predominantly base     $         procedure, by report                          or tooth spaces, per quadrant
      metal, two surfaces
                                              XVII. ORAL & MAXILLOFACIAL SURGERY            D7311 Alveoloplasty in conjunction with $
D6613 Onlay - cast predominantly base     $                                                       extractions – one to three teeth
      metal, three or more surfaces           D7111 Extraction, coronal remnants -      $         or tooth spaces, per quadrant
D6614 Onlay - cast noble metal, two       $         deciduous tooth                                                                    $
                                                                                            D7320 Alveoloplasty not in conjunction
      surfaces                                D7140 Extraction, erupted tooth or        $         with extractions - four or more
D6615 Onlay - cast noble metal, three     $         exposed root (evaluation and/or               teeth or tooth spaces, per
      or more surfaces                              forceps removal)                              quadrant
                                              D7210 Surgical removal of erupted         $   D7321 Alveoloplasty not in conjunction     $
D6624 Inlay - titanium                    $
                                                    tooth requiring elevation of                  with extractions – one to three
D6634 Onlay - titanium                    $         mucoperiosteal flap and removal               teeth, or tooth spaces, per
                                                    of bone and/or section of tooth               quadrant
D6710 Crown - indirect resin based        $
      composite                               D7220 Removal of impacted tooth - soft $      D7340 Vestibuloplasty - ridge extension    $
                                                    tissue                                        (secondary epithelialization)
D6720 Crown - resin with high noble       $
      metal                                   D7230 Removal of impacted tooth -         $
                                                    partially bony
D6721 Crown - resin with                  $
      predominantly base metal

November 2006                                                      Page 6
D7350 Vestibuloplasty - ridge extension $     D7540 Removal of reaction producing       $   D7872 Arthroscopy - diagnosis, with or    $
      (including soft tissue grafts,                foreign bodies, musculoskeletal               without biopsy
      muscle reattachment, revision of              system
                                                                                            D7873 Arthroscopy - surgical: lavage      $
      soft tissue attachment and                                                        $
                                              D7550 Partial                                       and lysis of adhesions
      management of hypertrophied
                                                    ostectomy/sequestrectomy for
      and hyperplastic tissue)                                                              D7874 Arthroscopy - surgical: disc        $
                                                    removal of non-vital bone
                                          $                                                       repositioning and stabilization
D7410 Excision of benign lesion up to
                                              D7560 Maxillary sinusotomy for removal $
      1.25 cm                                                                               D7875 Arthroscopy - surgical:             $
                                                    of tooth fragment or foreign
                                          $                                                       synovectomy
D7411 Excision of benign lesion greater             body
      than 1.25 cm                                                                      $   D7876 Arthroscopy - surgical:             $
                                              D7610 Maxilla - open reduction (teeth
                                          $                                                       discectomy
D7412 Excision of benign lesion,                    immobilized, if present)
      complicated                                                                       $   D7877 Arthroscopy - surgical:             $
                                              D7620 Maxilla - closed reduction (teeth
                                          $                                                       debridement
D7413 Excision of malignant lesion up               immobilized, if present)
      to 1.25 cm                                                                            D7880 Occlusal orthotic device, by        $
                                              D7630 Mandible - open reduction           $
                                          $                                                       report
D7414 Excision of malignant lesion                  (teeth immobilized, if present
      greater than 1.25 cm                          (simple)                                D7899 Unspecified TMD therapy, by         $
                                          $                                                       report
D7415 Excision of malignant lesion,           D7640 Mandible – closed reduction -       $
      complicated                                   teeth immobilized, if present)          D7910 Suture of recent small wounds       $
                                          $                                                       up to 5 cm
D7440 Excision of malignant tumor -           D7650 Malar and/or zygomatic arch -       $
      lesion up to 1.25 cm                          open reduction                          D7911 Complicated suture - up to 5 cm     $
D7441 Excision of malignant tumor –       $   D7660 Malar and/or zygomatic arch -       $   D7912 Complicated suture - greater        $
      lesion diameter greater than                  closed reduction                              than 5 cm
      1.25 cm
                                              D7670 Alveolus - closed reduction, may    $   D7920 Skin graft (identify defect         $
D7450 Removal of benign odontogenic       $         include stabilization of teeth                covered, location and type of
      cyst or tumor - lesion diameter                                                             graft)
                                              D7671 Alveolus - open reduction, may      $
      up to 1.25 cm
                                                    include stabilization of teeth          D7940 Osteoplasty - for orthognathic      $
D7451 Removal of benign odontogenic       $                                                       deformities
                                              D7680 Facial bones - complicated          $
      cyst or tumor – lesion diameter
                                                    reduction with fixation and             D7941 Osteotomy - mandibular rami         $
      greater than 1.25 cm
                                                    multiple surgical approaches
D7460 Removal of benign                   $                                                 D7943 Osteotomy - mandibular rami         $
                                              D7710 Maxilla - open reduction            $         with bone graft; includes
      nonodontogenic cyst or tumor -
      lesion diameter up to 1.25 cm                                                               obtaining the graft
                                              D7720 Maxilla - closed reduction          $
D7461 Removal of benign                   $                                                 D7944 Osteotomy - segmented or            $
                                              D7730 Mandible - open reduction           $
      nonodontogenic cyst or tumor –                                                              subapical
      lesion diameter greater than            D7740 Mandible - closed reduction         $
                                                                                            D7945 Osteotomy - body of mandible        $
      1.25 cm                                 D7750 Malar and/or zygomatic arch -       $
                                                                                            D7946 LeFort I – (maxilla - total)        $
D7465 Destruction of lesion(s) by         $         open reduction
      physical or chemical method, by                                                       D7947 LeFort I – (maxilla – segmented) $
                                              D7760 Malar and/or zygomatic arch -       $
      report                                        closed reduction                        D7948 LeFort II or LeFort III –           $
D7471 Removal of lateral exostosis –      $                                                       (osteoplasty of facial bones for
                                              D7770 Alveolus - open reduction           $
      (maxilla or mandible)                                                                       midface hypoplasia or retrusion)
                                                    stabilization of teeth
                                                                                                  - without bone graft
D7472 Removal of torus palatinus          $
                                              D7771 Alveolus - closed reduction         $
                                                                                            D7949 LeFort II or LeFort III - with      $
D7473 Removal of torus mandibularis       $         stabilization of teeth
                                                                                                  bone graft
D7485 Surgical reduction of osseous       $   D7780 Facial bones - complicated          $
                                                                                            D7950 Osseous, osteoperiosteal, or        $
      tuberosity                                    reduction with fixation and
                                                                                                  cartilage graft of mandible or
                                                    multiple surgical approaches
D7490 Radical resection of maxilla or     $                                                       maxilla - autogenous or
      mandible                                D7810 Open reduction of dislocation       $         nonautogenous, by report

D7510 Incision and drainage of abscess    $   D7820 Closed reduction of dislocation     $   D7951 Sinus augmentation with bone or $
      - intraoral soft tissue                                                                     bone substitutes
                                              D7830 Manipulation under anesthesia       $
D7511 Incision and drainage of abscess    $                                                 D7953 Bone replacement graft for ridge $
                                              D7840 Condylectomy                        $
      - intraoral soft tissue –                                                                   preservation - per site
      complicated (includes drainage          D7850 Surgical discectomy,                $
                                                                                            D7955 Repair of maxillofacial soft        $
      of multiple fascial spaces)                   with/without implant
                                                                                                  and/or hard tissue defect
D7520 Incision and drainage of            $   D7852 Disc repair                         $
                                                                                            D7960 Frenulectomy (frenectomy or     $
      abscess - extraoral soft tissue         D7854 Synovectomy                         $         frenotomy) - separate procedure
D7521 Incision and drainage of            $
                                              D7856 Myotomy                             $   D7963 Frenuloplasty                       $
      abscess - extraoral soft tissue-
      complicated (includes drainage          D7858 Joint reconstruction                $   D7970 Excision of hyperplastic tissue -   $
      of multiple fascial spaces)                                                                 per arch
                                              D7860 Arthrotomy                          $
D7530 Removal of foreign body from        $                                                 D7971 Excision of pericoronal gingiva     $
                                              D7865 Arthroplasty                        $
      mucosa, skin, or subcutaneous                                                         D7972 Surgical reduction of fibrous       $
      alveolar tissue                         D7870 Arthrocentesis                      $         tuberosity
                                              D7871 Non-arthroscopic lysis & lavage     $   D7980 Sialolithotomy                      $

November 2006                                                      Page 7
D7981 Excision of salivary gland, by       $   D8999 Unspecified orthodontic              $   D9942 Repair and/or reline of occlusal   $
      report                                         procedure, by report                           guard
D7982 Sialodochoplasty                     $   XIX. ADJUNCTIVE GENERAL SERVICES               D9950 Occlusion analysis - mounted       $
D7983 Closure of salivary fistula          $
                                               D9110 Palliative (emergency) treatment $
                                                                                              D9951 Occlusal adjustment - limited      $
D7990 Emergency tracheotomy                $         of dental pain - minor procedure
                                                                                              D9952 Occlusal adjustment - complete     $
D7991 Coronoidectomy                       $   D9120 Fixed partial denture sectioning     $
                                                                                              D9970 Enamel microabrasion               $
D7995 Synthetic graft - mandible or        $   D9210 Local anesthesia not in              $
      facial bones, by report                        conjunction with operative or            D9971 Odontoplasty 1-2 teeth; includes   $
                                                     surgical procedures                            removal of enamel projections
D7996 Implant - mandible for               $
      augmentation purposes                    D9211 Regional block anesthesia            $   D9972 External bleaching - per arch      $
      (excluding alveolar ridge), by
                                               D9212 Trigeminal division block            $   D9973 External bleaching - per tooth     $
D7997 Appliance removal (not by            $                                                  D9974 Internal bleaching - per tooth     $
                                               D9215 Local anesthesia                     $
      dentist who placed appliance),                                                          D9999 Unspecified adjunctive             $
      includes removal of archbar              D9220 Deep sedation/general                $         procedure, by report
                                                     anesthesia - first 30 minutes
D7998 Intraoral placement of a fixation    $
      device not in conjunction with a         D9221 Deep sedation/general                $
      fracture                                       anesthesia - each additional 15
D7999 Unspecified oral surgery             $         minutes
      procedure, by report                     D9230 Analgesia, anxiolysis, inhalation    $
                                                     of nitrous oxide
                                               D9241 Intravenous conscious                $
D8010 Limited orthodontic treatment of     $         sedation/analgesia - first 30
      the primary dentition                          minutes
D8020 Limited orthodontic treatment of     $   D9242 Intravenous conscious                $
      the transitional dentition                     sedation/analgesia - each
                                                     additional 15 minutes
D8030 Limited orthodontic treatment of     $
      the adolescent dentition                 D9248 Non-intravenous conscious            $
D8040 Limited orthodontic treatment of     $
      the adult dentition                      D9310 Consultation - diagnostic service    $
                                                     provided by dentist or physician
D8050 Interceptive orthodontic             $
                                                     other than requesting dentist or
      treatment of the primary
                                               D9410 House/extended care facility call    $
D8060 Interceptive orthodontic             $
      treatment of the transitional            D9420 Hospital call                        $
                                               D9430 Office visit for observation         $
D8070 Comprehensive orthodontic            $         (during regularly scheduled
      treatment of the transitional                  hours) - no other services
      dentition                                      performed
D8080 Comprehensive orthodontic            $   D9440 Office visit - after regularly       $
      treatment of the adolescent                    scheduled hours
                                               D9450 Case presentation, detailed and      $
D8090 Comprehensive orthodontic            $         extensive treatment planning
      treatment of the adult dentition
                                               D9610 Therapeutic parenteral drug,         $
D8210 Removable appliance therapy          $         single administration
D8220 Fixed appliance therapy              $   D9612 Therapeutic parental drugs, two      $
                                                     or more administrations,
D8660 Pre-orthodontic treatment visit      $
                                                     different medications
D8670 Periodic orthodontic treatment       $
                                               D9630 Other drugs and/or                   $
                                                     medicaments, by report
D8680 Orthodontic retention (removal       $
                                               D9910 Application of desensitizing         $
      of appliances, construction and
      placement of retainer(s))
                                               D9911 Application of desensitizing resin   $
D8690 Orthodontic treatment                $
                                                     for cervical and/or root surface,
      (alternative billing to a contract
                                                     per tooth
                                               D9920 Behavior management, by report $
D8691 Repair of orthodontic appliance      $
                                               D9930 Treatment of complications           $
D8692 Replacement of lost or broken        $
                                                     (post-surgical) - unusual
                                                     circumstances, by report
D8693 Rebonding or recementing;            $
                                               D9940 Occlusal guard, by report            $
      and/or repair, as required, of
      fixed retainers                          D9941 Fabrication of athletic              $

November 2006                                                        Page 8

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