| ADA Code | ADA Description | MAC Specialist |
| D0120 | Periodic oral evaluation - established patient | 50 |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver | 50 |
| D0150 | Comprehensive oral evaluation - new or established patient | 77 |
| D0160 | Detailed and extensive oral evaluation - problem focused | 83 |
| D0170 | Re-evaluation - limited, problem focused | 55 |
| D0180 | Comprehensive periodontal evaluation - new or established patient | 76 |
| D0425 | Caries susceptibility to oral diseases | 50 |
| D1110 | Prophylaxis - adult | 67 |
| D1120 | Prophylaxis - child | 50 |
| D1203 | Topical application of fluoride - child | 50 |
| D1204 | Topical application of fluoride - adult | 50 |
| D1206 | Topical fluoride varnish; therapeutic application for moderate to high caries risk patients | 50 |
| D1310 | Nutritional counseling for control of dental disease | 50 |
| D1320 | Tobacco counseling for control and prevention of oral disease | 50 |
| D1330 | Oral hygiene instructions | 50 |
| D4910 | Periodontal maintenance procedures following active therapy | 100 |
| D9430 | Office visit for observation (during regularly scheduled hours) - no other services performed | 78 |
| D9910 | Application of desensitizing medicament | 50 |
| ADA Code | ADA Description | |
| D0210 | Intraoral - complete series (including bite wings) | 35 |
| D0220 | Intraoral - periapical first film | 35 |
| D0230 | Intraoral - periapical each additional film | 35 |
| D0240 | Intraoral - occlusal film | 35 |
| D0250 | Extraoral - first film | 35 |
| D0260 | Extraoral - each additional film | 35 |
| D0270 | Bitewing - single film | 35 |
| D0272 | Bitewings - two films | 35 |
| D0273 | Bitewings - three films | 35 |
| D0274 | Bitewings - four films | 38 |
| D0277 | Vertical bitewings - 7 to 8 films | 64 |
| D0330 | Panoramic film | 68 |
| D0340 | Cephalometric film | 75 |
| FILLINGS AND BASIC SERVICES | ||
| ADA Code | ADA Description | |
| D0140 | Limited oral evaluation - problem focused | 70 |
| D0290 | Posterior - anterior or lateral skull and facial bone survey film | 78 |
| D0310 | Sialography | 190 |
| D0415 | Collection of microorganisms for culture and sensitivity-Bacteriologic Studies for Det of Path | 40 |
| D0417 | Collection and preparation of saliva sample for laboratory diagnostic testing | 53 |
| D0418 | Analysis of saliva sample | 133 |
| D0431 | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities | 40 |
| D0460 | Pulp vitality tests | 35 |
| D0470 | Diagnostic casts | 67 |
| D2140 | Amalgam - one surface, primary | 77 |
| permanent | 77 | |
| D2150 | Amalgam - two surfaces, primary | 95 |
| permanent | 95 | |
| D2160 | Amalgam - three surfaces, primary | 111 |
| permanent | 85 | |
| D2161 | Amalgam - four or more surfaces, primary | 115 |
| permanent | 95 | |
| D2330 | Resin-based composite - one surface, anterior | 92 |
| D2331 | Resin-based composite - two surfaces, anterior | 110 |
| D2332 | Resin-based composite - three surfaces, anterior | 134 |
| D2335 | Resin-based composite - four or more surfaces or involving incisal angle (anterior) | 159 |
| D2390 | Resin-based composite crown, anterior | 235 |
| D2391 | Resin-based composite - one surface, posterior, Primary | 110 |
| Permanent | 70 | |
| D2392 | Resin-based composite - two surfaces, posterior, Primary | 140 |
| Permanent | 85 | |
| D2393 | Resin-based composite - three surfaces, posterior, Primary | 170 |
| Permanent | 100 | |
| D2394 | Resin-based composite - four or more surfaces, posterior, Primary | 200 |
| Permanent | 100 | |
| D2410 | Gold foil - one surface | 345 |
| D2420 | Gold foil - two surfaces | 437 |
| PAIN MANAGEMENT AND ADJUNCTIVE SERVICES | ||
| ADA Code | ADA Description | |
| D9110 | Palliative (emergency) treatment dental pain - minor procedure | 68 |
| D9220 | Deep sedation/general anesthesia - first 30 minutes | 220 |
| D9221 | Deep sedation/general anesthesia - each additional 1 5 minutes | 107 |
| D9230 | Inhalation of nitrous oxide/analgesia, anxiolysis | 141 |
| D9241 | Intravenous conscious sedation/analgesia - first 30 minutes | 140 |
| D9310 | Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician | 130 |
| D9410 | House/extended care facility call | 107 |
| D9420 | Hospital or ambulatory surgical center call | 105 |
| D9440 | Office visit - after regular office hours | 75 |
| D9450 | Case presentation, detailed and extensive treatment planning | 52 |
| OTHER PREVENTIVE SERVICES | ||
| ADA Code | ADA Description | |
| D1351 | Sealant - per tooth | 33 |
| D1510 | Space maintainer - fixed - unilateral | 176 |
| D1515 | Space maintainer - fixed - bilateral | 240 |
| D1520 | Space maintainer - removable - unilateral | 273 |
| D1525 | Space maintainer - removable - bilateral | 330 |
| D1550 | Re-cementation of space maintainer | 45 |
| D1555 | Removal of fixed space maintainer | 95 |
| ORAL SURGERY, GUM TREATMENTS AND PROSTHETIC REPAIR | ||
| ADA Code | ADA Description | |
| D4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quad | 900 |
| D4211 | Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quad | 700 |
| D4230 | Anatomical Crown Exposure (four or more contiguous teeth per quad) | 160 |
| D4231 | Anatomical Crown Exposure (one to three teeth per quad) | 50 |
| D4240 | Ging flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quad | 875 |
| D4241 | Gingival flap procedure, including root planning - one to three contiguous teeth or tooth bounded spaces per quad | 725 |
| D4249 | Clinical crown lengthening - hard tissue | 636 |
| D4260 | Osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quad | 300 |
| D4261 | Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quad | 960 |
| D4263 | Bone replacement graft - first site in quad | 325 |
| D4264 | Bone replacement graft - each additional site in quad | 250 |
| D4270 | Pedicle soft tissue graft procedure | 498 |
| D4271 | Free soft tissue graft procedure (including donor site surgery) | 635 |
| D4273 | Sub epithelial connective tissue graft .procedures, per tooth | 906 |
| D4275 | Soft tissue allograft | 625 |
| D4320 | Provisional splinting - intracoronal | 230 |
| D4321 | Provisional splinting - extracoronal | 265 |
| D4341 | Periodontal scaling and root planning - four or more teeth per quad | 225 |
| D4342 | Periodontal scaling and root planning - one to three teeth per quad | 110 |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis | 130 |
| D5410 | Adjust complete denture - maxillary | 61 |
| D5411 | Adjust complete denture - mandibular | 61 |
| D5421 | Adjust partial denture - maxillary | 61 |
| D5422 | Adjust partial denture - mandibular | 61 |
| D5510 | Repair broken complete denture base | 125 |
| D5520 | Replace missing or broken teeth - complete denture (each tooth) | 94 |
| D5610 | Repair resin denture base | 110 |
| D5620 | Repair cast framework | 140 |
| D5630 | Repair or replace broken clasp | 134 |
| D5640 | Replace broken teeth - per tooth | 120 |
| D5650 | Add tooth to existing partial denture | 140 |
| D5660 | Add clasp to existing partial denture | 160 |
| D5710 | Rebase complete maxillary denture | 370 |
| D5711 | Rebase complete mandibular denture | 370 |
| D5720 | Rebase maxillary partial denture | 290 |
| D5721 | Rebase mandibular partial denture | 290 |
| D5730 | Reline complete maxillary denture (chairside) | 188 |
| D5731 | Reline complete mandibular denture (chairside) | 188 |
| D5740 | Reline maxillary partial denture (chairside) | 188 |
| D5741 | Reline mandibular partial denture (chairside) | 188 |
| D5620 | Reline complete maxillary denture (lab) | 320 |
| D5621 | Reline complete mandibular denture (lab) | 320 |
| D5760 | Reline maxillary partial denture (lab) | 320 |
| D5761 | Reline mandibular partial denture (lab) | 320 |
| D5850 | Tissue conditioning, maxillary | 95 |
| D5851 | Tissue conditioning, mandibular | 95 |
| D6090 | Repair implant supported prosthesis | 515 |
| D6091 | Replacement of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment | 424 |
| D6092 | Recement implant/abutment supported crown | 130 |
| D6093 | Recement implant/abutment supported fixed partial denture | 130 |
| D6095 | Repair implant abutment | 200 |
| D6100 | Implant removal | 300 |
| D6930 | Recement fixed partial denture | 100 |
| D7111 | Extraction, coronal remnants, deciduous tooth | 95 |
| D7140 | Extraction, erupted tooth or exposed root | 95 |
| D7210 | Surgical removal of erupted tooth | 154 |
| D7220 | Removal of impacted tooth - soft tissue | 195 |
| D7230 | Removal of impacted tooth - partial bony | 225 |
| D7240 | Removal of impacted tooth - completely bony | 290 |
| D7241 | Removal of impacted tooth - completely bony, with unusual surgical complications | 305 |
| D7250 | Surgical removal residual tooth roots (cutting procedure) | 165 |
| D7260 | Oroantral fistula closure | 501 |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | 269 |
| D7280 | Surgical access of an unerupted tooth | 270 |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | 250 |
| D7283 | Placement of device to facilitate eruption of impacted tooth | 115 |
| D7285 | Biopsy of oral tissue - hard (bone, tooth) | 425 |
| D7286 | Biopsy of oral tissue - soft | 205 |
| D7310 | Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quad | 210 |
| D7311 | Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quad | 175 |
| D7320 | Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces, per quad | 285 |
| D7321 | Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quad | 121 |
| D7340 | Vestibuloplasty - uncomplicated | 975 |
| D7350 | Vestibuloplasty - complicated | 1685 |
| D7410 | Excision of benign lesion up to 1.25 cm | 650 |
| D7411 | Excision of benign lesion greater than 1.25 cm | 650 |
| D7412 | Excision of benign lesion, complicated | 650 |
| D7413 | Excision of malignant lesion up to 1.25 cm | 800 |
| D7414 | Excision of malignant lesion greater than 1.25 cm | 800 |
| D7415 | Excision of malignant lesion, complicated | 800 |
| D7440 | Excision of malignant tumor - lesion diameter up to 1.25 cm | 800 |
| D7441 | Excision of malignant tumor - lesion diameter greater than 1.25 cm | 800 |
| D7450 | Removal of benign odontogenic cyst or tumor- lesion diameter up to 1.25 cm | 650 |
| D7451 | Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1 .25 cm | 650 |
| D7460 | Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1 .25 cm | 650 |
| D7461 | Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm | 665 |
| D7471 | Removal of lateral exostosis (maxilla or mandible) | 450 |
| D7472 | Removal of torus palatinus | 450 |
| D7473 | Removal of torus mandibularis | 478 |
| D7485 | Surgical reduction of osseous tuberosity | 550 |
| D7510 | Incision and drainage of abscess - intraoral soft tissue | 143 |
| D7511 | Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | 562 |
| D7520 | Incision and drainage of abscess - extraoral soft tissue | 562 |
| D7521 | Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) | 562 |
| D7530 | Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue | 200 |
| D7540 | Removal of reaction producing foreign bodies, musculoskeletal system | 225 |
| D7550 | Partial ostectomy/sequestrectomy for removal of non-vital bone | 206 |
| D7560 | Maxillary sinusotomy for removal of tooth fragment or foreign body | 1289 |
| D7610 | Maxilla - open reduction (simple) | 3694 |
| D7620 | Maxilla - closed reduction (simple) | 2829 |
| D7630 | Mandible - open reduction (simple) | 4151 |
| D7640 | Mandible - closed reduction (simple) | 3060 |
| D7650 | Malar and/or zygomatic arch - open reduction (simple) | 2599 |
| D7660 | Malar and/or zygomatic arch - closed reduction (simple) | 1346 |
| D7670 | Alveolus - closed reduction, may include stabilization of teeth (simple) | 902 |
| D7671 | Alveolus - open reduction, may include stabilization of teeth (simple) | 1913 |
| D7710 | Maxilla - open reduction (compound) , | 4358 |
| D7720 | Maxilla - closed reduction (compound) | 2987 |
| D7730 | Mandible - open reduction (compound) | 5383 |
| D7740 | Mandible - closed reduction (compound) | 3036 |
| D7750 | Malar and/or zygomatic arch - open reduction (compound) | 4181 |
| D7760 | Malar and/or zygomatic arch - closed reduction (compound) | 1570 |
| D7770 | Alveolus - open reduction stabilization of teeth (compound) | 2034 |
| D7771 | Alveolus - closed reduction stabilization of teeth (compound) | 1561 |
| D7960 | Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another | 251 |
| D7963 | Frenuloplasty | 423 |
| D7970 | Excision of hyperplastic tissue - per arch | 263 |
| D7971 | Excision of pericoronal gingiva | 250 |
| D9120 | Fixed partial denture sectioning | 44 |
| CROWNS AND MAJOR SERVICES | ||
| D2510 | Inlay - metallic - one surface | 455 |
| D2520 | Inlay - metallic - two surfaces | 475 |
| D2530 | Inlay - metallic - three or more surfaces | 487 |
| D2542 | Onlay - metallic - two surfaces | 465 |
| D2543 | Onlay - metallic - three surfaces | 560 |
| D2544 | Onlay - metallic - four or more surfaces | 570 |
| D2610 | Inlay - porcelain/ceramic - one surface | 445 |
| D2620 | Inlay - porcelain/ceramic - two surfaces | 546 |
| D2630 | Inlay - porcelain/ceramic - three or more surfaces | 592 |
| D2642 | Onlay - porcelain/ceramic - two surfaces | 660 |
| D2643 | Onlay - porcelain/ceramic - three surfaces | 685 |
| D2644 | Onlay - porcelain/ceramic - four or more surfaces | 698 |
| D2650 | Inlay - resin-based composite - one surface | 378 |
| D2651 | Inlay - resin-based composite - two surfaces | 445 |
| D2652 | Inlay - resin-based composite - three or more surfaces | 489 |
| D2662 | Onlay - resin-based composite - two surfaces | 450 |
| D2663 | Onlay - resin-based composite - three surfaces | 487 |
| D2664 | Onlay - resin-based composite - four or more surfaces | 510 |
| D2710 | Crown - resin-based composite (indirect) | 455 |
| D2712 | Crown - 3/4 resin-based composite (indirect) | 700 |
| D2720 | Crown - resin with high noble metal | 685 |
| D2721 | Crown - resin with predominantly base metal | 632 |
| D2722 | Crown - resin with noble metal | 641 |
| D2740 | Crown - porcelain/ceramic substrate | 740 |
| D2750 | Crown - porcelain fused to high noble metal | 740 |
| D2751 | Crown - porcelain fused to predominantly base metal | 690 |
| D2752 | Crown - porcelain fused to noble metal | 710 |
| D2780 | Crown - 3/4 cast high noble metal | 746 |
| D2781 | Crown - 3/4 cast predominantly base metal | 694 |
| D2782 | Crown - 3/4 cast noble metal | 715 |
| D2783 | Crown - 3/4 porcelain/ceramic | 770 |
| D2790 | Crown - full cast high noble metal | 756 |
| D2791 | Crown - full cast predominantly base metal | 700 |
| D2792 | Crown - full cast noble metal | 732 |
| D2794 | Crown - titanium | 626 |
| D2910 | Recement inlay, onlay, or partial coverage restoration | 66 |
| D2915 | Recement cast or prefabricated post and core | 57 |
| D2920 | Recement crown | 57 |
| D2930 | Prefabricated stainless steel crown - primary tooth | 150 |
| D2931 | Prefabricated stainless steel crown - permanent tooth | 185 |
| D2932 | Prefabricated resin crown | 210 |
| D2933 | Prefabricated stainless steel crown with resin window | 200 |
| D2934 | Prefabricated esthetic coated stainless steel crown - primary tooth | 199 |
| D2940 | Protective restoration | 66 |
| D2950 | Crown buildup - including any pins | 150 |
| D2951 | Pin retention - per tooth in addition to restoration | 45 |
| D2952 | Post and core in addition to crown, indirectly fabricated | 294 |
| D2954 | Prefabricated post & core in addition to crown | 200 |
| D2955 | Post removal (not in conjunction with endodontic therapy) | 139 |
| D2970 | Temporary crown (fractured tooth) | 165 |
| D2980 | Crown repair | 0 |
| D3110 | Pulp cap - direct (excluding final restoration) | 55 |
| D3120 | Pulp cap - indirect (excluding final restoration) | 44 |
| D3220 | Therapeutic pulpotomy (excluding final restoration) | 114 |
| D3222 | Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development | 114 |
| D3230 | Pulpal therapy - anterior, primary tooth (excluding final restoration) | 135 |
| D3240 | Pulpal therapy - posterior, primary tooth (excluding final restoration) | 141 |
| D3310 | Endodontic therapy, anterior tooth (excluding final restoration) | 610 |
| D3320 | Endodontic therapy, bicuspid tooth (excluding final restoration) | 745 |
| D3330 | Endodontic therapy, molar (excluding final restoration) | 950 |
| D3346 | Retreatment of previous root canal therapy- anterior | 917 |
| D3347 | Retreatment of previous root canal therapy- bicuspid | 1080 |
| D3348 | Retreatment of previous root canal therapy- molar | 1336 |
| D3351 | Apexification/recalcification/pulpal regeneration - initial visit ' | 240 |
| D3352 | Apexification/recalcification/pulpal regeneration - interim medication replacement | 139 |
| D3353 | Apexification/recalcification - final visit | 560 |
| D3410 | Apicoectomy/periradicular surgery - anterior | 670 |
| D3421 | Apicoectomy/periradicular surgery - bicuspid (first root) | 785 |
| D3425 | Apicoectomy/periradicular surgery - molar (first root) | 825 |
| D3426 | Apicoectomy/periradicular surgery (each additional root) | 183 |
| D3430 | Retrograde filling - per root | 130 |
| D3450 | Root amputation - per root | 207 |
| D3920 | Hemisection - (including root removal); not including root canal therapy | 305 |
| D3950 | Canal preparation and fitting of preformed dowel or post | 125 |
| MAJOR PROSTHETIC SERVICES | ||
| ADA Code | ADA Description | |
| D5110 | Complete denture - maxillary | 1385 |
| D5120 | Complete denture - mandibular | 1385 |
| D5130 | Immediate denture - maxillary | 1540 |
| D5140 | Immediate denture - mandibular | 1540 |
| D5211 | Maxillary partial denture - resin base (including any conventional clasps, rests, and teeth) | 810 |
| D5212 | Mandibular partial denture - resin base (including any conventional clasps, rests, and teeth) | 810 |
| D5213 | Max partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) | 1365 |
| D5214 | Mand partial denture -cast metal frame with resin denture bases (including clasps, rests, teeth) | 1365 |
| D5225 | Maxillary partial denture - flexible base (including clasps, rests, and teeth) | 1152 |
| D5226 | Mandibular partial denture - flexible base (including clasps, rests, and teeth) | 1152 |
| D5281 | Removable unilateral partial denture - one piece cast metal (including clasps and teeth) | 540 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | 790 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | 790 |
| D5810 | Interim complete denture (maxillary) | 450 |
| D5811 | Interim complete denture (mandibular) | 450 |
| D5820 | Interim partial denture (maxillary) | 360 |
| D5821 | Interim partial denture (mandibular) | 360 |
| D6010 | Surgical placement of implant body: endosteal implant | 1875 |
| D6012 | Surgical Placement of Interim Implant Body for Transitional Prosthetics: Endosteal Implant | 650 |
| D6040 | Surgical placement: eposteal implant | 6215 |
| D6050 | Surgical placement : transosteal implant | 4250 |
| D6056 | Prefabricated abutment - includes placement | 650 |
| D6057 | Custom abutment - includes placement | 650 |
| D6058 | Abutment supported porcelain/ceramic crown | 860 |
| D6059 | Abutment supported porcelain fused to metal crown (high noble metal) | 900 |
| D6060 | Abutment supported porcelain fused to metal crown (predominantly base metal) | 760 |
| D6061 | Abutment supported porcelain fused to metal crown (noble metal) | 834 |
| D6062 | Abutment supported cast metal crown (high noble metal) | 840 |
| D6063 | Abutment supported cast metal crown (predominantly base metal) | 775 |
| D6064 | Abutment supported cast metal crown (noble metal) | 840 |
| D6065 | Implant supported porcelain/ceramic crown | 965 |
| D6066 | Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | 965 |
| D6067 | Implant supported metal crown (titanium, titanium alloy, high noble metal) | 945 |
| D6068 | Abutment supported retainer for porcelain/ceramic FPD | 865 |
| D6069 | Abutment supported retainer for porcelain fused to metal FPD (high noble metal) | 850 |
| D6070 | Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) | 750 |
| D6071 | Abutment supported retainer for porcelain fused to metal FPD (noble metal) | 785 |
| D6072 | Abutment supported retainer for cast metal FPD (high noble metal) | 850 |
| D6073 | Abutment supported retainer for cast meta! FPD (predominantly base metal) | 779 |
| D6074 | Abutment supported retainer for cast metal FPD (noble metal) | 840 |
| D6075 | Implant supported retainer for ceramic FPD | 955 |
| D6076 | Implant supported retainer for porcelain fused to metal FPD (ti, ti alloy, high noble metal) | 935 |
| D6077 | Implant supported retainer for cast metal FPD (titanium, titanium alloy, high noble metal) | 930 |
| D6078 | Implant/abutment supported fixed denture for completely edentulous arch | 2375 |
| D6079 | Implant/abutment supported fixed denture for partially edentulous arch | 1590 |
| D6080 | Implant maintenance procedures | 225 |
| D6094 | Abutment supported crown (titanium) | 710 |
| D6194 | Abutment supported retainer crown for FPD (titanium) | 829 |
| D6205 | Pontic - indirect resin based composite | 678 |
| D6210 | Pontic - cast high noble metal | 756 |
| D6211 | Pontic - cast predominantly base metal | 700 |
| D6212 | Pontic - cast noble metal | 735 |
| D6214 | Pontic - titanium | 735 |
| D6240 | Pontic - porcelain fused to high noble metal | 740 |
| D6241 | Pontic - porcelain fused to predominantly base metal | 690 |
| D6242 | Pontic - porcelain fused to noble metal | 715 |
| D6245 | Pontic - porcelain/ceramic | 740 |
| D6250 | Pontic - resin with high noble metal | 716 |
| D6251 | Pontic - resin with predominantly base metal | 655 |
| D6252 | Pontic - resin with noble metal | 710 |
| D6253 | Provisional pontic | 1375 |
| D6545 | Cast metal retainer for resin bonded fixed prosthesis | 355 |
| D6548 | Porcelain/ceramic retainer for resin bonded fixed prosthesis | 590 |
| D6600 | Inlay - porcelain/ceramic, two surfaces | 563 |
| D6601 | Inlay - porcelain/ceramic, three or more surfaces | 611 |
| D6602 | Inlay - cast high noble metal, two surfaces | 615 |
| D6603 | Inlay - cast high noble metal, three or more surfaces | 675 |
| D6604 | Inlay - cast predominantly base metal, two surfaces | 562 |
| D6605 | Inlay - cast predominantly base metal, three or more surfaces | 580 |
| D6606 | Inlay - cast noble metal, two surfaces | 560 |
| D6607 | Inlay - cast noble metal, three or more surfaces | 615 |
| D6608 | Onlay - porcelain/ceramic, two surfaces | 663 |
| D6609 | Onlay - porcelain/ceramic, three or more surfaces | 725 |
| D6610 | Onlay - cast high noble metal, two surfaces | 675 |
| D6611 | Onlay - cash high noble metal, three or more surfaces | 569 |
| D6612 | Onlay - cast predominantly base metal, two surfaces | 562 |
| D66I3 | Onlay - cast predominantly base metal, three or more surfaces | 640 |
| D6614 | Onlay - cast noble metal, two surfaces | 615 |
| D6615 | Onlay - cast noble metal, three or more surfaces | 675 |
| D6624 | Inlay - titanium | 600 |
| D6634 | Onlay - titanium | 655 |
| D6710 | Crown - indirect resin based composite | 651 |
| D6720 | Crown - resin with high noble metal | 800 |
| D6721 | Crown - resin with predominantly base, metal | 685 |
| D6722 | Crown - resin with noble metal | 710 |
| D6740 | Crown - porcelain/ceramic | 740 |
| D6750 | Crown - porcelain fused to high noble metal | 740 |
| D6751 | Crown - porcelain fused to predominantly base metal | 690 |
| D6752 | Crown - porcelain fused to noble metal | 715 |
| D6780 | Crown - 3/4 cast high noble metal | 750 |
| D6781 | Crown - 3/4 cast predominantly base metal | 692 |
| D6782 | Crown - 3/4 cast noble metal | 720 |
| D6783 | Crown - 3/4 porcelain/ceramic | 775 |
| D6790 | Crown - full cast high noble metal | 758 |
| D6791 | Crown - full cast predominantly base metal | 700 |
| D6792 | Crown - full cast noble metal | 735 |
| D6793 | Provisional retainer crown | 375 |
| D6794 | Crown - titanium | 639 |
| D6970 | Post and core in addition to fixed partial denture retainer, indirectly fabricated | 273 |
| D6972 | Prefabricated post and core in addition to fixed partial denture retainer | 200 |
| D6973 | Core build up for retainer, including any pins | 185 |
| D6975 | Coping - metal | 420 |
