Create Treatment Plan

Treatment Plan Calculator

Code	Description
D0120	periodic oral evaluation
D0140	limited oral evaluation - problem focused
D0145	oral evaluation for a patient under three years of age and counseling with primary caregiver
D0150	comprehensive oral evaluation - new or established patient
D0160	detailed and extensive oral evaluation - problem-focused, by report
D0170	re-evaluation, limited, problem focused
D0171	re-evaluation - post-operative office visit
D0180	comprehensive periodontal evaluation - new or established patient
D0190	Screening of a patient
D0191	Assessment of a patient
D0210	intraoral - complete series of radiographic images
D0220	intraoral - periapical first radiographic image
D0230	intraoral - periapical each additional radiographic image
D0240	intraoral - occlusal radiographic image
D0250	extraoral - 2D projection radiographic image created using a stationary radiation source and detector
D0251	extra-oral posterior dental radiographic image
D0270	bitewing - single radiographic image
D0272	bitewings - two radiographic images
D0273	bitewings - three radiographic images
D0274	bitewings - four radiographic images
D0277	vertical bitewings - 7 to 8 radiographic images
D0310	sialography
D0320	temporomandibular joint arthrogram, including injection
D0321	other temporomandibular joint radiographic images, by report
D0322	tomographic survey
D0330	panoramic radiographic image
D0340	2D cephalometric radiographic imagae - acquisition, measurement and analysis
D0350	2D Oral/facial photographic images obtained intraorally or extraorally
D0351	3D photographic image
D0364	cone beam CT capture and interpretation with limited field of view - less than one whole jaw
D0365	cone beam CT capture and interpretation with field of view of one full dental arch - mandible
D0366	cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium
D0367	cone beam CT capture and interpretation with field of view of both jaws, with or without cranium
D0368	cone beam CT capture and interpretation for TMJ series including two or more exposures
D0369	maxillofacial MRI capture and interpretation
D0370	maxillofacial ultrasound capture and interpretation
D0371	sialoendoscopy capture and interpretation
D0380	cone beam CT image capture with limited field of view - less than one whole jaw
D0381	cone beam CT image capture with field of view of one full dental arch - mandible
D0382	cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium
D0383	cone beam CT image capture with field of view of both jaws, with or without cranium
D0384	cone beam CT image capture for TMJ series including two or more exposures
D0385	maxillofacial MRI image capture
D0386	maxillofacial ultrasound image capture
D0391	interpretation of diagnostic image by a practitioner not associated with capture of the image
D0393	treatment simulation using 3D image volume
D0394	digital subtraction of two or more images or image volumes of the same modality
D0395	fusion of two or more 3D image volumes of one or more modalities
D0411	HbA1c in office point of service testing
D0412	blood glucose level test - in-office using a glucose meter
D0414	Lab processing of microbial specimen to include culture and sensitivity studies.
D0415	collection of microorganisms for culture and sensitivity
D0416	viral culture
D0417	collection and preparation of saliva sample for laboratory diagnostic testing
D0418	analysis of saliva sample
D0419	assessment of salivary flow by measurement
D0422	collection and preparation of genetic sample material for laboratory analysis and report
D0423	genetic test for susceptibility to diseases-specimen analysis
D0425	caries susceptibility tests
D0431	adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesi
D0460	pulp vitality tests
D0470	diagnostic casts
D0472	accession of tissue, gross examination, prep and transmission of written report
D0473	accession of tissue, gross and microscopic examination, prep and transmission of written report
D0474	accession of tissue, gross and microscopic exam, includes assessment of margins, prep and transmission of report
D0480	processing and intepretation of exfoliative cytological smears, including preparation and transmission of written report
D0486	laboratory accession of transepithelial cytologic sample, micro exam, preparation and transmission of written report
D0502	other oral pathology procedures, by report
D0600	non-ionizing diagnostic procedure
D0601	caries risk assessment and documentation, with a finding of low risk
D0602	caries risk assessment and documentation, with a finding of moderate risk
D0603	caries risk assessment and documentation, with a finding of high risk
D0604	antigen testing for a public health related pathogen, including coronavirus
D0605	antibody testing for a public health related pathogen, including coronavirus
D0701	panoramic radiographic image – image capture only
D0702	2-D cephalometric radiographic image – image capture only
D0703	2-D oral/facial photographic image obtained intra-orally or extra-orally – image capture only
D0704	3-D photographic image – image capture only
D0705	extra-oral posterior dental radiographic image – image capture only
D0706	intraoral - occlusal radiographic image - image capture only
D0707	intraoral - periapical radiographic image - image capture only
D0708	intraoral - bitewing radiographic image - image capture only
D0709	intraoral - complete series of radiographic images - image capture only
D0999	unspecified diagnostic procedure, by report
D1110	prophylaxis - adult
D1120	prophylaxis - child
D1206	topical application of fluoride varnish
D1208	Topical application of fluoride - excluding varnish
D1310	nutritional counseling for control of dental disease
D1320	tobacco counseling for the control and prevention of oral disease
D1321	counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with
D1330	oral hygiene instructions
D1351	sealant - per tooth
D1351	sealant - per tooth
D1351	sealant - per tooth
D1351	sealant - per tooth
D1352	preventive resin restoration - permanent tooth
D1352	preventive resin restoration - permanent tooth
D1352	preventive resin restoration - permanent tooth
D1352	preventive resin restoration - permanent tooth
D1353	sealant repair - per tooth
D1353	sealant repair - per tooth
D1353	sealant repair - per tooth
D1353	sealant repair - per tooth
D1354	interim caries arresting medicament application - per tooth
D1355	caries preventive medicament application – per tooth
D1510	space maintainer - fixed, unilateral - per quadrant
D1516	space maintainer - fixed - bilateral, maxillary
D1517	space maintainer - fixed - bilateral, mandibular
D1520	space maintainer - removable, unilateral - per quadrant
D1526	space maintainer - removable - bilateral, maxillary
D1527	space maintainer - removable - bilateral, mandibular
D1551	re-cement or re-bond bilateral space maintainer - maxillary
D1552	re-cement or re-bond bilateral space maintainer - mandibular
D1553	re-cement or re-bond unilateral space maintainer - per quadrant
D1556	removal of fixed unilateral space maintainer - per quadrant
D1557	removal of fixed bilateral space maintainer - maxillary
D1558	removal of fixed bilateral space maintainer - mandibular
D1575	distal shoe space maintainer - fixed, unilateral - per quadrant
D1999	Unspecified preventive procedure, by report
D2140	amalgam - one surface, primary or permanent
D2140	amalgam - one surface, primary or permanent
D2150	amalgam - two surfaces, primary or permanent
D2150	amalgam - two surfaces, primary or permanent
D2160	amalgam - three surfaces, primary or permanent
D2160	amalgam - three surfaces, primary or permanent
D2161	amalgam - four or more surfaces, primary or permanent
D2161	amalgam - four or more surfaces, primary or permanent
D2330	resin-based composite - one surface, anterior
D2330	resin-based composite - one surface, anterior
D2330	resin-based composite - one surface, anterior
D2330	resin-based composite - one surface, anterior
D2331	resin-based composite - two surfaces, anterior
D2331	resin-based composite - two surfaces, anterior
D2331	resin-based composite - two surfaces, anterior
D2331	resin-based composite - two surfaces, anterior
D2332	resin-based composite - three surfaces, anterior
D2332	resin-based composite - three surfaces, anterior
D2332	resin-based composite - three surfaces, anterior
D2332	resin-based composite - three surfaces, anterior
D2335	resin-based composite - four or more surfaces or involving incisal angle (anterior)
D2335	resin-based composite - four or more surfaces or involving incisal angle (anterior)
D2335	resin-based composite - four or more surfaces or involving incisal angle (anterior)
D2335	resin-based composite - four or more surfaces or involving incisal angle (anterior)
D2390	resin-based composite crown, anterior
D2390	resin-based composite crown, anterior
D2390	resin-based composite crown, anterior
D2390	resin-based composite crown, anterior
D2391	resin-based composite - one surface, posterior
D2392	resin-based composite - two surfaces, posterior
D2393	resin-based composite - three surfaces, posterior
D2394	resin-based composite - four or more surfaces, posterior
D2410	gold foil - one surface
D2420	gold foil - two surfaces
D2430	gold foil - three surfaces
D2510	inlay - metallic - one surface
D2520	inlay - metallic - two surfaces
D2530	inlay - metallic - three or more surfaces
D2542	onlay metallic, two surfaces
D2543	onlay-metallic-three surfaces
D2544	onlay-metallic-four or more surfaces
D2610	inlay - porcelain/ceramic - one surface
D2620	inlay - porcelain/ceramic - two surfaces
D2630	inlay - porcelain/ceramic - three or more surfaces
D2642	onlay - porcelain/ceramic - two surfaces
D2643	onlay - porcelain/ceramic - three surfaces
D2644	onlay - porcelain/ceramic - four or more surfaces
D2650	inlay - composite/resin - one surface
D2651	inlay - composite/resin - two surfaces
D2652	inlay - composite/resin - three or more surfaces
D2662	onlay - composite/resin - two surfaces
D2663	onlay - composite/resin - three surfaces
D2664	onlay - composite/resin - four or more surfaces
D2710	crown,resin-based composite (indirect)
D2712	crown - 3/4 resin-based composite (indirect)
D2720	crown - resin with high noble metal
D2721	crown - resin with predominantly base metal
D2722	crown - resin with noble metal
D2740	crown - porcelain/ceramic
D2750	crown - porcelain fused to high noble metal
D2751	crown - porcelain fused to predominantly base metal
D2752	crown - porcelain fused to noble metal
D2753	crown - porcelain fused to titanium and titanium alloys
D2780	crown, 3/4 cast high noble metal
D2781	crown, 3/4 cast predominantly base metal
D2782	crown, 3/4 cast noble metal
D2783	crown, 3/4 porcelain/ceramic
D2790	crown - full cast high noble metal
D2791	crown - full cast predominantly base metal
D2792	crown - full cast noble metal
D2794	crown - titanium and titanium alloys
D2799	provisional crown - further treatment or completion of diagnosis necessary prior to final impression
D2910	recement or re-bond inlay, onlay, veneer or partial coverage restoration
D2915	recement or re-bond cast indirectlty fabricated or prefabricated post and core
D2920	recement or re-bond crown
D2921	reattachment of tooth fragment, incisal edge or cusp
D2928	prefabricated porcelain/ceramic crown – permanent tooth
D2929	Prefabricated porcelain/ceramic crown - primary tooth
D2930	prefabricated stainless steel crown - primary tooth
D2931	prefabricated stainless steel crown - permanent tooth
D2932	prefabricated resin crown
D2932	prefabricated resin crown
D2933	prefabricated stainless steel crown with resin window
D2933	prefabricated stainless steel crown with resin window
D2934	prefabricated esthetic coated stainless steel crown - primary tooth
D2934	prefabricated esthetic coated stainless steel crown - primary tooth
D2940	protective restoration
D2940	protective restoration
D2941	interim therapeutic restoration-primary dentition
D2941	interim therapeutic restoration-primary dentition
D2949	restorative foundation for an indirect restoration
D2950	Core buildup, including any pins when required
D2951	pin retention - per tooth, in addition to restoration
D2952	cast post and core in addition to crown
D2953	each additional indirectly fabricated post, same tooth
D2954	prefabricated post and core in addition to crown
D2955	post removal
D2957	each additional prefabricated post, same tooth
D2960	labial veneer (resin laminate) - direct
D2960	labial veneer (resin laminate) - direct
D2961	labial veneer (resin laminate) - indirect
D2961	labial veneer (resin laminate) - indirect
D2962	labial veneer (porcelain laminate) - indirect
D2962	labial veneer (porcelain laminate) - indirect
D2975	coping
D2980	crown repair necessitated by restorative material failure
D2981	inlay repair necessitated by restorative material failure
D2982	onlay repair necessitated by restorative material failure
D2983	veneer repair necessitated by restorative material failure
D2990	resin infiltration of incipient smooth surface lesions
D2999	unspecified restorative procedure, by report
D3110	pulp cap - direct (excluding final restoration)
D3110	pulp cap - direct (excluding final restoration)
D3120	pulp cap - indirect (excluding final restoration)
D3120	pulp cap - indirect (excluding final restoration)
D3220	therapeutic pulpotomy (excluding final restoration)
D3220	therapeutic pulpotomy (excluding final restoration)
D3221	pulpal debridement, primary and permanent teeth
D3221	pulpal debridement, primary and permanent teeth
D3222	partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
D3230	pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
D3230	pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
D3240	pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
D3240	pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
D3240	pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
D3310	endodontic therapy, anterior tooth (excluding final restoration)
D3310	endodontic therapy, anterior tooth (excluding final restoration)
D3320	endodontic therapy, premolar tooth (excluding final restoration)
D3320	endodontic therapy, premolar tooth (excluding final restoration)
D3320	endodontic therapy, premolar tooth (excluding final restoration)
D3320	endodontic therapy, premolar tooth (excluding final restoration)
D3330	endodontic therapy, molar tooth (excluding final restoration)
D3330	endodontic therapy, molar tooth (excluding final restoration)
D3330	endodontic therapy, molar tooth (excluding final restoration)
D3330	endodontic therapy, molar tooth (excluding final restoration)
D3331	treatment of root canal obstruction, non-surgical access
D3332	incomplete endodontic therapy; inoperable, unrestorable or fractured tooth
D3333	internal tooth repair of performation defects
D3346	retreatment of previous root canal therapy - anterior
D3346	retreatment of previous root canal therapy - anterior
D3347	retreatment of previous root canal therapy - bicuspid
D3347	retreatment of previous root canal therapy - bicuspid
D3347	retreatment of previous root canal therapy - bicuspid
D3347	retreatment of previous root canal therapy - bicuspid
D3348	retreatment of previous root canal therapy - molar
D3348	retreatment of previous root canal therapy - molar
D3348	retreatment of previous root canal therapy - molar
D3351	Apexification/recalcification-initial visit (apical closure/calcific repair of perforations, root resorption, etc
D3351	Apexification/recalcification-initial visit (apical closure/calcific repair of perforations, root resorption, etc
D3352	Apexification/recalcification/pulpal regeneration - interim medication replacement
D3352	Apexification/recalcification/pulpal regeneration - interim medication replacement
D3353	apexification/recalcification - final visit (includes completed root
D3353	apexification/recalcification - final visit (includes completed root
D3355	Pupal regeneration-initial visit
D3355	Pupal regeneration-initial visit
D3356	Pulpal regeneration-interim medicament replacement
D3356	Pulpal regeneration-interim medicament replacement
D3357	Pulpal regeneration-completion of treatment
D3357	Pulpal regeneration-completion of treatment
D3410	Apicoectomy - anterior
D3410	Apicoectomy - anterior
D3421	Apicoectomy - premolar (first root)
D3421	Apicoectomy - premolar (first root)
D3421	Apicoectomy - premolar (first root)
D3421	Apicoectomy - premolar (first root)
D3425	Apicoectomy - molar (first root)
D3425	Apicoectomy - molar (first root)
D3425	Apicoectomy - molar (first root)
D3425	Apicoectomy - molar (first root)
D3426	Apicoectomy (each additional root)
D3426	Apicoectomy (each additional root)
D3426	Apicoectomy (each additional root)
D3426	Apicoectomy (each additional root)
D3428	bone graft in conjunction with periradicular surgery-per tooth, single site
D3429	bone graft in conjunction with periradicular surgery -each additional contiguous tooth in same surgical site
D3430	retrograde filling - per root
D3430	retrograde filling - per root
D3431	biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery
D3432	guided tissue regeneration, resorbable barrier, per site in conjunction with periradicular surgery
D3450	root amputation - per root
D3450	root amputation - per root
D3450	root amputation - per root
D3450	root amputation - per root
D3460	endodontic endosseous implant
D3470	intentional reimplantation (including necessary splinting)
D3471	surgical repair of root resorption - anterior
D3471	surgical repair of root resorption - anterior
D3472	surgical repair of root resorption – premolar
D3472	surgical repair of root resorption – premolar
D3472	surgical repair of root resorption – premolar
D3472	surgical repair of root resorption – premolar
D3473	surgical repair of root resorption – molar
D3473	surgical repair of root resorption – molar
D3473	surgical repair of root resorption – molar
D3473	surgical repair of root resorption – molar
D3501	surgical exposure of root surface without apicoectomy or repair of root resorption – anterior
D3501	surgical exposure of root surface without apicoectomy or repair of root resorption – anterior
D3502	surgical exposure of root surface without apicoectomy or repair of root resorption – premolar
D3502	surgical exposure of root surface without apicoectomy or repair of root resorption – premolar
D3502	surgical exposure of root surface without apicoectomy or repair of root resorption – premolar
D3502	surgical exposure of root surface without apicoectomy or repair of root resorption – premolar
D3503	surgical exposure of root surface without apicoectomy or repair of root resorption – molar
D3503	surgical exposure of root surface without apicoectomy or repair of root resorption – molar
D3503	surgical exposure of root surface without apicoectomy or repair of root resorption – molar
D3503	surgical exposure of root surface without apicoectomy or repair of root resorption – molar
D3910	surgical procedure for isolation of tooth with rubber dam
D3920	hemisection (including any root removal), not including root canal therapy
D3920	hemisection (including any root removal), not including root canal therapy
D3920	hemisection (including any root removal), not including root canal therapy
D3920	hemisection (including any root removal), not including root canal therapy
D3950	canal preparation and fitting of preformed dowel or post
D3999	unspecified endodontic procedure, by report
D4210	gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
D4210	gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
D4210	gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
D4210	gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant
D4211	gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
D4211	gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
D4211	gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
D4211	gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant
D4212	gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth
D4230	anatomical crown exposure - four or more contiguous teeth or tooth bounded spaces per quadrant
D4230	anatomical crown exposure - four or more contiguous teeth or tooth bounded spaces per quadrant
D4230	anatomical crown exposure - four or more contiguous teeth or tooth bounded spaces per quadrant
D4230	anatomical crown exposure - four or more contiguous teeth or tooth bounded spaces per quadrant
D4231	anatomical crown exposure - one to three teeth or tooth bounded spaces per quadrant
D4231	anatomical crown exposure - one to three teeth or tooth bounded spaces per quadrant
D4231	anatomical crown exposure - one to three teeth or tooth bounded spaces per quadrant
D4231	anatomical crown exposure - one to three teeth or tooth bounded spaces per quadrant
D4240	gingival flap procedure, including root planning - four or more contiguous teeth or tooth bounded spaces per quadrant
D4240	gingival flap procedure, including root planning - four or more contiguous teeth or tooth bounded spaces per quadrant
D4240	gingival flap procedure, including root planning - four or more contiguous teeth or tooth bounded spaces per quadrant
D4240	gingival flap procedure, including root planning - four or more contiguous teeth or tooth bounded spaces per quadrant
D4241	gingival flap procedure - including root planing -one to three contiguous teeth or tooth bounded spaces per quadrant
D4241	gingival flap procedure - including root planing -one to three contiguous teeth or tooth bounded spaces per quadrant
D4241	gingival flap procedure - including root planing -one to three contiguous teeth or tooth bounded spaces per quadrant
D4241	gingival flap procedure - including root planing -one to three contiguous teeth or tooth bounded spaces per quadrant
D4245	apically positioned flap
D4245	apically positioned flap
D4245	apically positioned flap
D4245	apically positioned flap
D4249	clinical crown lengthening - hard tissue
D4260	osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant
D4260	osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant
D4260	osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant
D4260	osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant
D4261	osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
D4261	osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
D4261	osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
D4261	osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant
D4263	Bone replacement graft - retained natural tooth - first site in quadrant
D4264	Bone replacement graft - retained natural tooth - each additional site in quadrant
D4265	biologic materials to aid in soft and osseous tissue regeneration
D4266	guided tissue regeneration - resorbable barrier, per site
D4267	guided tissue regeneration - nonresorbable barrier, per site (Includes membrane removal)
D4268	surgical revision procedure, per tooth
D4270	pedicle soft tissue graft procedure
D4273	autogenous connective tissue graft procedure, per first tooth, implant or endentulous tooth position in graft
D4274	mesial/distal wedge procedure single tooth(when not perormed in conjunction with surgical procedures in the same area
D4275	non-autogenous connective tissue graft (including recipient site and donor material) first tooth implant
D4276	combined connective tissue and double pedicle graft, per tooth
D4277	free soft tissue graft procedure (including recipient and donor surgical sites)first tooth, implant, or edentulous tooth
D4278	free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous position
D4283	autogenous connective tissue graft procedure - each additional contiguous tooth, implant or edentulous tooth
D4285	non-autogenous connective tissue graft procedure - each additional contiguous tooth, implant or edentulous tooth
D4320	provisional splinting - intracoronal
D4321	provisional splinting - extracoronal
D4341	periodontal scaling and root planing - four or more teeth per quadrant
D4341	periodontal scaling and root planing - four or more teeth per quadrant
D4341	periodontal scaling and root planing - four or more teeth per quadrant
D4341	periodontal scaling and root planing - four or more teeth per quadrant
D4342	periodontal scaling and root planing - one - three teeth, per quadrant
D4342	periodontal scaling and root planing - one - three teeth, per quadrant
D4342	periodontal scaling and root planing - one - three teeth, per quadrant
D4342	periodontal scaling and root planing - one - three teeth, per quadrant
D4346	scaling in presence of generalized moderate or severe gingival inflammation
D4355	full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit
D4381	localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
D4910	periodontal maintenance
D4920	unscheduled dressing change (by someone other than treating dentist or their staff)
D4921	gingival irrigation - per quadrant
D4999	unspecified periodontal procedure, by report
D5110	complete denture - maxillary
D5120	complete denture - mandibular
D5130	immediate denture - maxillary
D5140	immediate denture - mandibular
D5211	maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth)
D5212	mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth)
D5213	maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests
D5214	mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rest
D5221	immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)
D5221	immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth)
D5222	immediate mandibular partial denture - resin base
D5222	immediate mandibular partial denture - resin base
D5223	immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materi
D5223	immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materi
D5224	Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping mater
D5224	Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping mater
D5225	maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth)
D5226	mandibular partial denture - flexible base (including any retentive/clasping materials, rests, and teeth)
D5282	removable unil partial denture � one piece cast metal (includ retentive/clasping materials, rests, and teeth), maxillary
D5283	removable unil partial denture � one piece cast metal (incl. retentive/clasping materials, rests, and teeth), mandibular
D5284	removable unil. part denture � one piece flex. base (incl. retentive/clasping materials, rests, and teeth), per quadrant
D5286	removable unil. part denture � one piece resin (incl. retentive/clasping materials, rests, and teeth), per quadrant
D5410	adjust complete denture - maxillary
D5411	adjust complete denture - mandibular
D5421	adjust partial denture - maxillary
D5422	adjust partial denture - mandibular
D5511	repair broken complete denture base, mandibular
D5512	repair broken complete denture base, maxillary
D5520	replace missing or broken teeth - complete denture (each tooth)
D5611	repair resin partial denture base, mandibular
D5612	repair resin partial denture base, maxillary
D5621	repair cast partial framework, mandibular
D5622	repair cast partial framework, maxillary
D5630	repair or replace broken retentive/clasping materials - per tooth
D5640	replace broken teeth - per tooth
D5650	add tooth to existing partial denture
D5660	add clasp to existing partial denture - per tooth
D5670	replace all teeth and acrylic on cast metal framework (maxillary)
D5671	replace all teeth and acrylic on cast metal framework (mandibular)
D5710	rebase complete maxillary denture
D5711	rebase complete mandibular denture
D5720	rebase maxillary partial denture
D5721	rebase mandibular partial denture
D5730	reline complete maxillary denture (direct)
D5731	reline complete mandibular denture (direct)
D5740	reline maxillary partial denture (direct)
D5741	reline mandibular partial denture (direct)
D5750	reline complete maxillary denture (indirect)
D5751	reline complete mandibular denture (indirect)
D5760	reline maxillary partial denture (indirect)
D5761	reline mandibular partial denture (indirect)
D5810	interim complete denture (maxillary)
D5810	interim complete denture (maxillary)
D5811	interim complete denture (mandibular)
D5811	interim complete denture (mandibular)
D5820	interim partial denture (including retentive/clasping materials, rests, and teeth), (maxillary)
D5820	interim partial denture (including retentive/clasping materials, rests, and teeth), (maxillary)
D5821	interim partial denture (including retentive/clasping materials, rests, and teeth), (mandibular)
D5821	interim partial denture (including retentive/clasping materials, rests, and teeth), (mandibular)
D5850	tissue conditioning, maxillary
D5851	tissue conditioning, mandibular
D5862	precision attachment, by report
D5863	Overdenture-complete maxillary
D5864	Overdenture-partial maxillary
D5865	Overdenture - complete mandibular
D5866	Overdenture-partial mandibular
D5867	replacement of replaceable part of semi-precision or precision attachment
D5875	modification of removable prosthesis following implant surgery
D5876	add metal substructure to acrylic full denture (per arch)
D5899	unspecified removable prosthodontic procedure, by report
D5911	facial moulage (sectional)
D5912	facial moulage (complete)
D5913	nasal prosthesis
D5914	auricular prosthesis
D5915	orbital prosthesis
D5916	ocular prosthesis
D5919	facial prosthesis
D5922	nasal septal prosthesis
D5923	ocular prosthesis, interim
D5924	cranial prosthesis
D5925	facial augmentation implant prosthesis
D5926	nasal prosthesis, replacement
D5927	auricular prosthesis, replacement
D5928	orbital prosthesis, replacement
D5929	facial prosthesis, replacement
D5931	obturator prosthesis, surgical
D5932	obturator prosthesis, definitive
D5933	obturator prosthesis, modification
D5934	mandibular resection prosthesis with guide flange
D5935	mandibular resection prosthesis without guide flange
D5936	obturator prosthesis, interim
D5937	trismus appliance (not for TMD treatment)
D5951	feeding aid
D5952	speech aid prosthesis, pediatric
D5953	speech aid prosthesis, adult
D5954	palatal augmentation prosthesis
D5955	palatal lift prosthesis, definitive
D5958	palatal lift prosthesis, interim

Member

<Member Benefits

Member Information

Relationship:

Plan Description:

Product ID:

Date of Service

Treatment Plan Name (20 characters maximum)

Select a Dentist

View All Procedure Codes

Procedure Code

Billed Amount

Unit Number

Add Another Code

By deleting this Procedure Code, it will be deleted permanently. You will need to add an additional procedure code if deleted by mistake.

Disclaimer 1: This is the most current information that we have; however, it is the patient’s responsibility to check with the dental provider to verify they are participating and accept the patient’s plan. This is neither an authorization nor a guarantee of eligibility, benefits or payment.
Disclaimer 2: Some ADA codes require dental review. Please be sure to include narrative or xrays. Predeterminations are highly recommended for procedures over $500.
Disclaimer 3: The information contained is a summary of the patient’s history. Not all plan information is listed. Absence of information indicates no history exists for the patient for that category/procedure but does not indicate that there are no limits on the plan.
Disclaimer 4: This document including attachments, may include confidential and/or proprietary information as designated by state or federal law, and may be used only by the person or entity to which it is addressed. If the reader of this document is not the intended recipient or his or her authorized agent, the reader is hereby notified that any dissemination, distribution, or copying of this fax is prohibited. If you have received this document in error, please notify the sender by calling customer service at 1-800-445-9090 and delete this document and its attachments immediately.
Disclaimer 5: Treatment plan and guarantee are valid for 30 days. Member must remain eligible for benefits at the time services are rendered. Guarantee is only applicable to services included in the original treatment plan as submitted to the Treatment Plan Calculator. Providers should: a) Include same-day services (e.g., evaluations, prophys, diagnostic, etc.) in the Treatment Plan Calculator to ensure accumulations reflect appropriately, and b) Consult with the member and the extended care team, to account for any additional services during the 30-day guarantee period, up to and including all services provided during the initial evaluation.
Disclaimer 6: The guarantee will not apply if: a) Member has utilized additional services from this or any other provider during the 30-day guarantee period, or b) Provider is on the Provider Outlier Program (POP).
Disclaimer 7: If your Treatment Plan Calculator amount does not match your reimbursement, please contact Customer Service at 800-822-5353 to discuss whether you qualify for a reimbursement adjustment.

Member

Member Information

Required Field