NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

D0120 Periodic oral evaluation - established patient $58 $58 $41

D0140 Limited oral evaluation - problem focused $70 $90 $49

D0145Oral evaluation for patient under three years of age and

counseling with primary caregiver$57 $57 $40

D0150 Comprehensive oral evaluation - new or established patient $81 $81 $57

D0160Detailed and extensive oral evaluation - problem focused, by

report$126 $126 $88

D0170Re-evaluation - limited, problem focused (established patient; not

post-operative visit)$67 $67 $47

D0180Comprehensive periodontal evaluation - new or established

patient$98 $168 $69

D0210 Intraoral - complete series (including bitewings) $124 $124 $87

D0220 Intraoral - periapical first radiographic image $26 $26 $18

D0230 Intraoral - periapical each additional radiographic image $20 $20 $14

D0240 Intraoral - occlusal radiographic image $28 $28 $20

D0250Extraoral – 2D projection radiographic image created using a

stationary radiation source, and detector$61 $61 $43

D0251 Extraoral - posterior dental radiographic image $26 $26 $18

D0270 Bitewing - single radiographic image $20 $20 $14

D0272 Bitewings - two radiographic images $41 $41 $29

D0273 Bitewings - three radiographic images $47 $47 $33

D0274 Bitewings - four radiographic images $61 $61 $43

D0277 Vertical bitewings - 7 to 8 radiographic images $90 $90 $63

D0320 Temporomandibular joint arthrogram, including injection $40 $40 $28

D0330 Panoramic radiographic image $99 $99 $69

D03402D cephalometric radiographic image – acquisition, measurement

and analysis$61 $61 $43

D0460 Pulp vitality tests $39 $39 $27

PAR ALLOWED AMOUNTS

Confidential and Proprietary - Regence BlueShield

Participating Dental Reimbursement Rates

Effective January 1, 2018

All published Regence BlueShield Administrative Guidelines apply.

Payment shall be per the terms of your Provider Agreement and the Member’s benefit plan.

All services performed must be within the scope of the provider’s license. The absence of a code from this list does not

necessarily mean the service is not paid to the fee schedule. Please notify Regence BlueShield if you have questions

concerning any code that may or may not be included on this list. The inclusion/exclusion of codes/fees from this list does

not necessarily indicate coverage or lack thereof.

Effective 1/1/2018 RBS Metro Dental 1

Click the Bookmarks Tab to see fee schedules for previous effective dates

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D1110 Prophylaxis – adult $112 $112 $78

D1120 Prophylaxis - child $73 $73 $51

D1206 Topical fluoride varnish $37 $37 $26

D1208 Topical application of fluoride – excluding varnish $37 $37 $26

D1330 Oral hygiene instructions $57 $57 $40

D1351 Sealant - per tooth $48 $48 $34

D1352Preventive resin restoration in a moderate to high caries risk

patient - permanent tooth$73 $73 $51

D1510 Space maintainer - fixed - unilateral $303 $303 $212

D1515 Space maintainer - fixed - bilateral $406 $406 $284

D1520 Space maintainer - removable – unilateral $283 $283 $198

D1525 Space maintainer - removable - bilateral $399 $399 $279

D1550 Re-cement or re-bond space maintainer $54 $54 $38

D1575 Distal shoe space maintainer -- fixed / unilateral $303 $303 $212

D1555 Removal of fixed space maintainer $35 $35 $25

D2140 Amalgam - one surface, primary or permanent $126 $126 $88

D2150 Amalgam - two surfaces, primary or permanent $183 $183 $128

D2160 Amalgam - three surfaces, primary or permanent $219 $219 $153

D2161 Amalgam - four or more surfaces, primary or permanent $250 $250 $175

D2330 Resin-based composite - one surface, anterior $157 $157 $110

D2331 Resin- based composite - two surfaces, anterior $200 $200 $140

D2332 Resin-based composite - three surfaces, anterior $245 $245 $172

D2335Resin-based composite - four or more surfaces involving incisal

angle (anterior)$285 $285 $200

D2390 Resin-based composite crown - anterior $285 $285 $200

D2391 Resin-based composite - one surface, posterior $173 $173 $121

D2392 Resin-based composite - two surfaces, posterior $232 $232 $162

D2393 Resin-based composite - three surfaces, posterior $285 $285 $200

D2394 Resin-based composite - four or more surfaces, posterior $318 $318 $223

D2510 Inlay - metallic - one surface $580 $580 $406

D2520 Inlay - metallic - two surfaces $657 $657 $460

D2530 Inlay - metallic - three or more surfaces $882 $882 $617

D2542 Onlay - metallic - two surfaces $632 $632 $442

D2543 Onlay - metallic - three surfaces $917 $917 $642

D2544 Onlay - metallic - four or more surfaces $1,001 $1,001 $701

D2610 Inlay - porcelain/ceramic - one surface $580 $580 $406

D2620 Inlay - porcelain/ceramic - two surfaces $664 $664 $465

D2630 Inlay - porcelain/ceramic - three or more surfaces $808 $808 $566

D2642 Onlay - porcelain/ceramic - two surfaces $683 $683 $478

D2643 Onlay - porcelain/ceramic - three surfaces $973 $973 $681

D2644 Onlay - porcelain/ceramic - four or more surfaces $1,066 $1,066 $746

D2650 Inlay - resin-based composite - one surface $556 $556 $389

D2651 Inlay - resin based composite - two surfaces $606 $606 $424

D2652 Inlay- resin based composite - three or more surfaces $657 $657 $460

D2662 Onlay - resin based composite - two surfaces $632 $632 $442

D2663 Onlay - resin based composite - three surfaces $742 $742 $519

D2664 Onlay - resin based composite - four or more surfaces $816 $816 $571

Effective 1/1/2018 RBS Metro Dental 2

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2710 Crown - resin-based composite (indirect) $333 $333 $233

D2712 Crown - 3/4 resin-based composite (indirect) $1,001 $1,001 $701

D2720 Crown - resin with high noble metal $1,006 $1,006 $704

D2721 Crown - resin with predominantly base metal $1,001 $1,001 $701

D2722 Crown - resin with noble metal $1,001 $1,001 $701

D2740 Crown - porcelain/ceramic $1,200 $1,200 $840

D2750 Crown - porcelain fused to high noble metal $1,142 $1,142 $799

D2751 Crown - porcelain fused to predominantly base metal $1,001 $1,001 $701

D2752 Crown - porcelain fused to noble metal $1,033 $1,033 $723

D2780 Crown - 3/4 cast high noble metal $1,006 $1,006 $704

D2781 Crown - 3/4 cast predominately base metal $1,001 $1,001 $701

D2782 Crown - 3/4 cast noble metal $1,001 $1,001 $701

D2783 Crown - 3/4 porcelain/ceramic $1,006 $1,006 $704

D2790 Crown - full cast high noble metal $1,066 $1,066 $746

D2791 Crown - full cast predominantly base metal $1,001 $1,001 $701

D2792 Crown - full cast noble metal $1,006 $1,006 $704

D2794 Crown - titanium $1,051 $1,051 $736

D2910Re-cement or re-bond inlay, onlay, veneer or partial coverage

restoration$79 $79 $55

D2915Re-cement or re-bond indirectly fabricated or prefabricated post

and core$76 $76 $53

D2920 Re-cement or re-bond crown $84 $84 $59

D2921 Reattachment of tooth fragment, incisal edge or cusp $282 $282 $197

D2930 Prefabricated stainless steel crown - primary tooth $229 $229 $160

D2931 Prefabricated stainless steel crown - permanent tooth $232 $232 $162

D2932 Prefabricated resin crown $218 $218 $153

D2933 Prefab stainless steel crown with resin window $232 $232 $162

D2934Prefabricated esthetic coated stainless steel crown - primary

tooth$232 $232 $162

D2940 Protective Restoration $84 $84 $59

D2941 Interim therapeutic restoration – primary dentition $81 $81 $57

D2949 Restorative foundation for an indirect restoration $207 $207 $145

D2950 Core buildup, including any pins when required $217 $217 $152

D2952 Post and core in addition to crown, indirectly fabricated $340 $340 $238

D2954 Prefabricated post and core in addition to crown $276 $276 $193

D2955 Post removal $253 $253 $177

D2957 Each additional prefabricated post - same tooth $113 $113 $79

D2960 Labial veneer (resin laminate) – chairside $723 $723 $506

D2961 Labial veneer (resin laminate) – laboratory $820 $820 $574

D2962 Labial veneer (porcelain laminate) – laboratory $891 $891 $624

D2971Additional procedures to construct new crown under existing

partial denture framework$101 $101 $71

D2975 Coping $253 $253 $177

D2980 Crown repair necessitated by restorative material failure $152 $152 $106

D2990 Resin infiltration of incipient smooth surface lesions $61 $61 $43

D3110 Pulp cap - direct (excluding final restoration) $64 $74 $45

Effective 1/1/2018 RBS Metro Dental 3

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D3220

Therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application of

medicament

$145 $167 $102

D3221 Pulpal debridement, primary and permanent teeth $149 $171 $104

D3222Partial pulpotomy for apexogenesis - permanent tooth with

incomplete root development$126 $145 $88

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth $168 $193 $118

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth $228 $262 $160

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $657 $920 $460

D3320 Endodontic therapy, premolar tooth (excluding final restoration) $783 $1,071 $548

D3330 Endodontic therapy, molar tooth (excluding final restoration) $944 $1,340 $661

D3331 Treatment of root canal obstruction; non-surgical access $113 $130 $79

D3332Incomplete endodontic therapy; inoperable, unrestorable or

fractured tooth$284 $327 $199

D3333 Internal root repair of perforation defects $354 $407 $248

D3346 Retreatment of previous root canal therapy - anterior $709 $950 $496

D3347 Retreatment of previous root canal therapy - premolar $828 $1,150 $580

D3348 Retreatment of previous root canal therapy - molar $1,066 $1,400 $746

D3351Apexification/recalcification - initial visit (apical closure/calcific

repair of perforations, root resorption, etc.)$177 $250 $124

D3352 Apexification/recalcification - interim mediation replacement $51 $59 $36

D3353

Apexification/recalcification - final visit (includes completed root

canal therapy - apical closure/calcific repair of perforations, root

resorption, etc.)

$217 $262 $152

D3355 Pulpal regeneration – initial visit $177 $250 $124

D3356 Pulpal regeneration – interim medication replacement $51 $59 $36

D3357 Pulpal regeneration – completion of treatment $217 $262 $152

D3410 Apicoectomy - anterior $552 $950 $386

D3421 Apicoectomy - premolar (first root) $552 $950 $386

D3425 Apicoectomy - molar (first root) $552 $950 $386

D3426 Apicoectomy (each additional root) $206 $305 $144

D3427 Periradicular surgery without apicoectomy $189 $325 $132

D3428Bone graft in conjunction with periradicular surgery – per tooth,

single site$371 $427 $260

D3429Bone graft in conjunction with periradicular surgery – each

additional contiguous tooth in the same surgical site$244 $281 $171

D3430 Retrograde filling - per root $155 $203 $109

D3431Biologic materials to aid in soft and osseous tissue regeneration in

conjunction with periradicular surgery$208 $310 $146

Effective 1/1/2018 RBS Metro Dental 4

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D3432Guided tissue regeneration, resorbable barrier, per site, in

conjunction with periradicular surgery$215 $247 $151

D3450 Root amputation - per root $244 $281 $171

D3470 Intentional reimplantation (including necessary splinting) $495 $569 $347

D3920Hemisection (including any root removal), not including root canal

therapy$387 $445 $271

D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant$387 $567 $271

D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or

tooth bounded spaces per quadrant$177 $204 $124

D4240Gingival flap procedure, including root planning - four or more

contiguous teeth or tooth bounded spaces per quadrant$631 $726 $442

D4241Gingival flap procedure, including root planning - one to three

contiguous teeth or tooth bounded spaces per quadrant$354 $407 $248

D4245 Apically positioned flap $482 $645 $337

D4249 Clinical crown lengthening - hard tissue $626 $875 $438

D4260

Osseous surgery (including elevation of full thickness flap and

closure) - four or more contiguous teeth or tooth bounded spaces

per quadrant

$1,010 $1,400 $707

D4261

Osseous surgery (including elevation of full thickness flap and

closure) - one to three contiguous teeth or tooth bounded spaces

per quadrant

$707 $1,150 $495

D4263 Bone replacement graft - first site in quadrant $371 $427 $260

D4264 Bone replacement graft - each additional site in quadrant $244 $281 $171

D4265 Biologic materials to aid in soft and osseous tissue regeneration $208 $310 $146

D4266 Guided tissue regeneration - resorbable barrier, per site $318 $446 $223

D4267Guided tissue regeneration - nonresorbable barrier, per site

(includes membrane removal)$215 $280 $151

D4268 Surgical revision procedure, per tooth $207 $246 $145

D4270 Pedicle soft tissue graft procedure $643 $823 $450

D4273

Autogenous connective tissue graft procedure (including donor

and recipient surgical sites) first tooth, implant, or edentulous

tooth position in graft

$808 $929 $566

D4274

Distal or proximal wedge procedure (when not performed in

conjunction with surgical procedures in the same anatomical

area)

$386 $444 $270

D4275

Non-autogenous connective tissue graft (including recipient site

and donor material) first tooth, implant, or edentulous tooth

position in graft

$636 $1,005 $445

D4276 Combined connective tissue and double pedicle graft, per tooth $449 $735 $314

D4277

Free soft tissue graft procedure (including recipient and donor

surgical sites) first tooth, implant or edentulous tooth position in

graft

$808 $995 $566

Effective 1/1/2018 RBS Metro Dental 5

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D4278

Free soft tissue graft procedure (including recipient and donor

surgical sites) each additional contiguous tooth, implant or

edentulous tooth position in same graft site

$398 $515 $279

D4283

Autogenous connective tissue graft procedure (including donor

and recipient surgical sites) – each additional contiguous tooth,

implant or edentulous tooth position in same graft site

$606 $697 $424

D4285

Non-autogenous connective tissue graft procedure (including

recipient surgical site and donor material) – each additional

contiguous tooth, implant or edentulous tooth position in same

graft site

$478 $754 $335

D4341Periodontal scaling and root planning - four or more teeth per

quadrant $207 $282 $145

D4342Periodontal scaling and root planning - one to three teeth per

quadrant$131 $151 $92

D4346Scaling in presence of generalized moderate or severe gingival

inflamation -- full mouth, after oral evaluation$162 $186 $113

D4355Full mouth debridement to enable comprehensive evaluation and

diagnosis on a subsequent visit$128 $147 $90

D4910 Periodontal maintenance $162 $186 $113

D4920Unscheduled dressing change (by someone other than treating

dentist)$32 $37 $22

D5110 Complete denture - maxillary $1,288 $1,481 $902

D5120 Complete denture - mandibular $1,288 $1,481 $902

D5130 Immediate denture - maxillary $1,288 $1,481 $902

D5140 Immediate denture - mandibular $1,288 $1,481 $902

D5211Maxillary partial denture - resin base (including any conventional

clasps, rests and teeth)$1,368 $1,573 $958

D5212Mandibular partial denture - resin base (including any

conventional clasps, rests and teeth)$1,368 $1,573 $958

D5213Maxillary partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)$1,374 $1,580 $962

D5214Mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)$1,374 $1,580 $962

D5221Immediate maxillary partial denture – resin base (including any

conventional clasps, rests and teeth)$1,368 $1,573 $958

D5222Immediate mandibular partial denture – resin base (including any

conventional clasps, rests and teeth)$1,368 $1,573 $958

D5223

Immediate maxillary partial denture – cast metal framework with

resin denture bases (including any conventional clasps, rests and

teeth)

$1,374 $1,580 $962

D5224

Immediate mandibular partial denture – cast metal framework

with resin denture bases (including any conventional clasps, rests

and teeth)

$1,374 $1,580 $962

Effective 1/1/2018 RBS Metro Dental 6

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D5225Maxillary partial denture - flexible base (including any clasps, rests

and teeth)$1,368 $1,573 $958

D5226Mandibular partial denture - flexible base (including any clasps,

rests and teeth)$1,368 $1,573 $958

D5281Removable unilateral partial denture - one piece cast metal

(including clasps and teeth)$859 $988 $601

D5410 Adjust complete denture - maxillary $80 $92 $56

D5411 Adjust complete denture - mandibular $80 $92 $56

D5421 Adjust partial denture - maxillary $66 $76 $46

D5422 Adjust partial denture - mandibular $66 $76 $46

D5511 Repair broken complete denture base, mandibular $116 $133 $81

D5512 Repair broken complete denture base, maxillary $116 $133 $81

D5520 Replace missing or broken teeth - complete denture (each tooth) $116 $133 $81

D5611 Repair resin partial denture base, mandibular $120 $138 $84

D5612 Repair broken complete denture base, maxillary $120 $138 $84

D5621 Repair cast partial framework, mandibular $185 $213 $130

D5622 Repair cast partial framework, maxillary $185 $213 $130

D5630 Repair or replace broken clasp - per tooth $135 $155 $95

D5640 Replace broken teeth - per tooth $114 $131 $80

D5650 Add tooth to existing partial denture $162 $186 $113

D5660 Add clasp to existing partial denture - per tooth $164 $189 $115

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $714 $821 $500

D5671Replace all teeth and acrylic on cast metal framework

(mandibular)$714 $821 $500

D5710 Rebase complete maxillary denture $473 $544 $331

D5711 Rebase complete mandibular denture $473 $544 $331

D5720 Rebase maxillary partial denture $473 $544 $331

D5721 Rebase mandibular partial denture $473 $544 $331

D5730 Reline complete maxillary denture (chairside) $259 $298 $181

D5731 Reline complete mandibular denture (chairside) $259 $298 $181

D5740 Reline maxillary partial denture (chairside) $226 $260 $158

D5741 Reline mandibular partial denture (chairside) $226 $260 $158

D5750 Reline complete maxillary denture (laboratory) $390 $449 $273

D5751 Reline complete mandibular denture (laboratory) $390 $449 $273

D5760 Reline maxillary partial denture (laboratory) $368 $423 $258

D5761 Reline mandibular partial denture (laboratory) $368 $423 $258

D5850 Tissue conditioning, maxillary $91 $105 $64

D5851 Tissue conditioning, mandibular $91 $105 $64

D5863 Overdenture – complete maxillary $1,275 $1,469 $893

D5864 Overdenture – partial maxillary $1,368 $1,573 $958

D5865 Overdenture – complete mandibular $1,275 $1,469 $893

D5866 Overdenture – partial mandibular $1,368 $1,573 $958

D6010 Surgical placement of implant body: endosteal implant $2,062 $2,371 $1,443

D6055 Connecting bar – implant supported or abutment supported $633 $728 $443

Effective 1/1/2018 RBS Metro Dental 7

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6056 Prefabricated abutment – includes modification and placement $424 $488 $297

D6057 Custom fabricated abutment - includes placement $677 $779 $474

D6058 Abutment supported porcelain/ceramic crown $1,200 $1,380 $840

D6059Abutment supported porcelain fused to metal crown (high noble

metal)$1,200 $1,380 $840

D6060Abutment supported porcelain fused to metal crown

(predominantly base metal)$1,001 $1,151 $701

D6061Abutment supported porcelain fused to metal crown (noble

metal)$1,033 $1,188 $723

D6062 Abutment supported cast metal crown (high noble metal) $1,066 $1,226 $746

D6063Abutment supported cast metal crown (predominantly base

metal)$1,001 $1,151 $701

D6064 Abutment supported cast metal crown (noble metal) $1,006 $1,157 $704

D6065 Implant supported porcelain/ceramic crown $1,200 $1,380 $840

D6066Implant supported porcelain fused to metal crown (titanium,

titanium allow, high noble metal)$1,200 $1,380 $840

D6067Implant supported metal crown (titanium, titanium alloy, high

noble metal)$1,066 $1,226 $746

D6068 Abutment supported retainer for porcelain/ceramic FPD $1,200 $1,380 $840

D6069Abutment supported retainer for porcelain fused to metal FPD

(high noble metal)$1,200 $1,380 $840

D6070Abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)$1,001 $1,151 $701

D6071Abutment supported retainer for porcelain fused to metal FPD

(noble metal)$1,033 $1,188 $723

D6072Abutment supported retainer for cast metal FPD (high noble

metal)$1,066 $1,226 $746

D6073Abutment supported retainer for cast metal FPD (predominantly

base metal)$1,001 $1,151 $701

D6074 Abutment supported retainer for cast metal FPD (noble metal) $1,006 $1,157 $704

D6075 Implant supported retainer for ceramic FPD $1,200 $1,380 $840

D6076Implant supported retainer porcelain fused to metal FPD

(titanium, titanium alloy, or high noble metal)$1,200 $1,380 $840

D6081

Scaling and debridement in the presence of inflammation or

mucositis of a single implant, including cleaning of the implant

surfaces, without flap entry and closure

$131 $151 $92

D6085 Provisional implant crown $475 $546 $333

D6090 Repair implant supported prosthesis, by report $429 $493 $300

D6092 Re-cement or re-bond implant/abutment supported crown $77 $89 $54

D6093Re-cement or re-bond implant/abutment supported fixed partial

denture$107 $123 $75

D6094 Abutment supported crown (titanium) $1,051 $1,209 $736

D6095 Repair implant abutment, by report $253 $291 $177

D6096 Remove broken implant retaining screw $139 $160 $97

Effective 1/1/2018 RBS Metro Dental 8

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6100 Implant removal, by report $212 $244 $148

D6110Implant/abutment supported removable denture for edentulous

arch - maxillary$1,288 $1,481 $902

D6111Implant/abutment supported removable denture for edentulous

arch – mandibular$1,288 $1,481 $902

D6112Implant/abutment supported removable denture for partially

edentulous arch – maxillary$1,368 $1,573 $958

D6113Implant /abutment supported removable denture for partially

edentulous arch - mandibular$1,368 $1,573 $958

D6194 Abutment supported retainer crown for cast metal FPD (titanium) $1,051 $1,209 $736

D6205 Pontic - indirect resin based composite $404 $465 $283

D6210 Pontic - cast high noble metal $951 $1,094 $666

D6211 Pontic - cast predominantly base metal $951 $1,094 $666

D6212 Pontic - cast noble metal $951 $1,094 $666

D6214 Pontic - titanium $951 $1,094 $666

D6240 Pontic - porcelain fused to high noble metal $960 $1,104 $672

D6241 Pontic - porcelain fused to predominantly base metal $951 $1,094 $666

D6242 Pontic - porcelain fused to noble metal $960 $1,104 $672

D6245 Pontic - porcelain/ceramic $960 $1,104 $672

D6250 Pontic - resin with high noble metal $951 $1,094 $666

D6251 Pontic - resin with predominantly base metal $951 $1,094 $666

D6252 Pontic - resin with noble metal $951 $1,094 $666

D6545 Retainer- cast metal for resin bonded fixed prosthesis $505 $581 $354

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $849 $976 $594

D6549 Resin retainer-for resin bonded fixed prosthesis $500 $575 $350

D6608 Onlay - porcelain/ceramic, two surfaces $632 $727 $442

D6609 Onlay - porcelain/ceramic, three or more surfaces $1,038 $1,194 $727

D6610 Onlay - cast high noble metal, two surfaces $593 $682 $415

D6611 Onlay - cast high noble metal, three or more surfaces $714 $821 $500

D6612 Onlay - cast predominantly base metal, two surfaces $593 $682 $415

D6613 Onlay - cast predominantly base metal, three or more surfaces $714 $821 $500

D6614 Onlay - cast noble metal, two surfaces $593 $682 $415

D6615 Onlay - cast noble metal, three or more surfaces $714 $821 $500

D6624 Inlay - titanium $1,001 $1,151 $701

D6634 Onlay - titanium $991 $1,140 $694

D6710 Crown - indirect resin based composite $1,001 $1,151 $701

D6720 Crown - resin with high noble metal $1,001 $1,151 $701

D6721 Crown - resin with predominantly base metal $1,001 $1,151 $701

D6722 Crown - resin with noble metal $1,001 $1,151 $701

D6740 Crown - porcelain/ceramic $1,200 $1,380 $840

D6750 Crown - porcelain fused to high noble metal $1,142 $1,313 $799

D6751 Crown - porcelain fused to predominantly base metal $1,001 $1,151 $701

D6752 Crown - porcelain fused to noble metal $1,033 $1,188 $723

D6780 Crown - 3/4 cast high noble metal $1,006 $1,157 $704

Effective 1/1/2018 RBS Metro Dental 9

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6781 Crown - 3/4 cast predominantly base metal $1,001 $1,151 $701

D6782 Crown - 3/4 cast noble metal $1,001 $1,151 $701

D6783 Crown - 3/4 porcelain/ceramic $1,006 $1,157 $704

D6790 Crown - full cast high noble metal $1,066 $1,226 $746

D6791 Crown - full cast predominantly base metal $1,001 $1,151 $701

D6792 Crown - full cast noble metal $1,006 $1,157 $704

D6794 Crown - titanium $1,051 $1,209 $736

D6930 Re-cement or re-bond fixed partial denture $126 $145 $88

D6980Fixed partial denture repair necessitated by restorative material

failure$191 $220 $134

D7111 Extraction, coronal remnants - primary tooth $107 $123 $75

D7140Extraction, erupted tooth or exposed root (elevation and/or

forceps removal)$139 $160 $97

D7210

Surgical removal of erupted tooth requiring removal of bone

and/or sectioning of tooth, and including elevation of

mucoperiosteal flap if indicated

$258 $297 $181

D7220 Removal of impacted tooth - soft tissue $273 $314 $191

D7230 Removal of impacted tooth - partially bony $354 $407 $248

D7240 Removal of impacted tooth - completely bony $404 $505 $283

D7241Removal of impact tooth - completely bony, with unusual surgical

complications$429 $601 $300

D7250 Surgical removal of residual tooth roots (cutting procedure) $212 $300 $148

D7251 Coronectomy – intentional partial tooth removal $359 $450 $251

D7260 Oroantral fistula closure $480 $552 $336

D7261 Primary closure of a sinus perforation $51 $60 $36

D7270Tooth reimplantation and/or stabilization of accidentally evulsed

or displaced tooth$483 $573 $338

D7280 Surgical access of an unerupted tooth $404 $530 $283

D7282 Mobilization of erupted or malpositioned tooth to aid eruption $106 $122 $74

D7285 Incisional biopsy of oral tissue - hard (bone, tooth) $343 $408 $240

D7286 Incisional biopsy of oral tissue - soft $266 $312 $186

D7290 Surgical repositioning of teeth $420 $499 $294

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $149 $171 $104

D7310Alveoloplasty in conjunction with extractions - four or more teeth

or tooth spaces, per quadrant$172 $198 $120

D7311Alveoloplasty in conjunction with extractions - one to three teeth

or tooth spaces, per quadrant$165 $197 $116

D7320Alveoloplasty not in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant$224 $258 $157

D7321Alveoloplasty not in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant$224 $258 $157

D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $545 $627 $382

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CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts,

muscle reattachment, revisions of soft tissue attachment and

management of hypertrophied and hyperplastic tissue)

$606 $720 $424

D7410 Excision of benign lesion up to 1.25 cm $228 $275 $160

D7411 Excision of benign lesion greater than 1.25 cm $303 $360 $212

D7412 Excision of benign lesion, complicated $354 $420 $248

D7450Removal of benign odontogenic cyst or tumor - lesion diameter up

to 1.25 cm$342 $500 $239

D7451Removal of benign odontogenic cyst or tumor - lesion diameter

greater than 1.25 cm$521 $800 $365

D7465 Destruction of lesion(s) by physical or chemical method, by report $80 $92 $56

D7471 Removal of lateral exostosis (maxilla or mandible) $338 $389 $237

D7472 Removal of torus palatinus $338 $389 $237

D7473 Removal of torus mandibularis $369 $600 $258

D7485 Surgical reduction of osseous tuberosity $338 $389 $237

D7510 Incision and drain of abscess - intraoral soft tissue $150 $200 $105

D7511Incision and drainage of abscess - intraoral soft tissue -

complicated (includes drainage of multiple fascial spaces)$490 $564 $343

D7530Removal of foreign body from mucosa, skin, or subcutaneous

alveolar tissue$159 $183 $111

D7540Removal of reaction producing foreign bodies, musculoskeletal

system$132 $157 $92

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $227 $270 $159

D7560Maxillary sinusotomy for removal of tooth fragment or foreign

body$442 $525 $309

D7880 Occlusal orthotic device, by report $495 $569 $347

D7881 Occlusal orthotic device adjustment $80 $92 $56

D7910 Suture of recent small wounds up to 5 cm $208 $239 $146

D7911 Complicated suture - up to 5 cm $295 $339 $207

D7912 Complicated suture - greater than 5 cm $354 $407 $248

D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or

maxilla – autogenous or nonautogenous, by report$1,278 $1,470 $895

D7953 Bone replacement graft for ridge preservation - per site $308 $400 $216

D7960Frenulectomy – also known as frenectomy or frenotomy -

separate procedure not incidental to another$404 $465 $283

D7963 Frenuloplasty $180 $266 $126

D7970 Excision of hyperplastic tissue - per arch $202 $285 $141

D7971 Excision of periocoronal gingiva $162 $186 $113

D7972 Surgical reduction of fibrous tuberosity $338 $389 $237

D9110 Palliative (emergent) treatment of dental pain - minor procedure $126 $126 $88

D9120 Fixed partial denture sectioning $157 $157 $110

D9222 Deep sedation/general anesthesia - first 15 minutes $161 $191 $112

Effective 1/1/2018 RBS Metro Dental 11

NON-PAR

ADA CODE

CDT 2018DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D9223Deep sedation/general anesthesia – each subsequent 15 minute

increment$146 $174 $102

D9239Intravenous moderate (conscious) sedation/analgesia- first 15

minutes$124 $124 $87

D9243Intravenous moderate (conscious) sedation/analgesia – each

subsequent 15 minute increment$113 $113 $79

D9248 Non-intravenous conscious sedation $81 $81 $57

D9410 House/extended care facility call $68 $68 $48

D9420 Hospital or ambulatory surgical center call $73 $73 $51

D9430Office visit for observation (during regularly scheduled hours) - no

other services performed$36 $36 $25

D9440 Office visit - after regularly scheduled hours $102 $102 $71

D9940 Occlusal guard, by report $480 $480 $336

D9942 Repair and/or reline of occlusal guard $53 $53 $37

D9943 Occlusal guard adjustment $80 $91 $56

Effective 1/1/2018 RBS Metro Dental 12

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

D0120 Periodic oral evaluation - established patient $58 $58 $41

D0140 Limited oral evaluation - problem focused $70 $90 $49

D0145Oral evaluation for patient under three years of age and counseling

with primary caregiver$57 $57 $40

D0150 Comprehensive oral evaluation - new or established patient $81 $81 $57

D0160Detailed and extensive oral evaluation - problem focused, by

report$126 $126 $88

D0170Re-evaluation - limited, problem focused (established patient; not

post-operative visit)$67 $67 $47

D0180 Comprehensive periodontal evaluation - new or established patient $98 $168 $69

D0210 Intraoral - complete series (including bitewings) $124 $124 $87

D0220 Intraoral - periapical first radiographic image $26 $26 $18

D0230 Intraoral - periapical each additional radiographic image $20 $20 $14

D0240 Intraoral - occlusal radiographic image $28 $28 $20

D0250Extraoral – 2D projection radiographic image created using a

stationary radiation source, and detector$61 $61 $43

D0251 Extraoral - posterior dental radiographic image $26 $26 $18

D0270 Bitewing - single radiographic image $20 $20 $14

D0272 Bitewings - two radiographic images $41 $41 $29

D0273 Bitewings - three radiographic images $47 $47 $33

D0274 Bitewings - four radiographic images $61 $61 $43

D0277 Vertical bitewings - 7 to 8 radiographic images $90 $90 $63

D0320 Temporomandibular joint arthrogram, including injection $40 $40 $28

D0330 Panoramic radiographic image $99 $99 $69

D03402D cephalometric radiographic image – acquisition, measurement

and analysis$61 $61 $43

D0460 Pulp vitality tests $39 $39 $27

D1110 Prophylaxis – adult $112 $112 $78

D1120 Prophylaxis - child $73 $73 $51

D1206 Topical fluoride varnish $37 $37 $26

D1208 Topical application of fluoride – excluding varnish $37 $37 $26

D1330 Oral hygiene instructions $57 $57 $40

D1351 Sealant - per tooth $48 $48 $34

D1352Preventive resin restoration in a moderate to high caries risk

patient - permanent tooth$73 $73 $51

D1510 Space maintainer - fixed - unilateral $303 $303 $212

D1515 Space maintainer - fixed - bilateral $406 $406 $284

D1520 Space maintainer - removable – unilateral $283 $283 $198

D1525 Space maintainer - removable - bilateral $399 $399 $279

D1550 Re-cement or re-bond space maintainer $54 $54 $38

D1575 Distal shoe space maintainer -- fixed / unilateral $303 $303 $212

D1555 Removal of fixed space maintainer $35 $35 $25

D2140 Amalgam - one surface, primary or permanent $126 $126 $88

D2150 Amalgam - two surfaces, primary or permanent $183 $183 $128

D2160 Amalgam - three surfaces, primary or permanent $219 $219 $153

PAR ALLOWED AMOUNTS

Confidential and Proprietary - Regence BlueShieldParticipating Dental Reimbursement Rates

Effective July 1, 2017

All published Regence BlueShield Administrative Guidelines apply.Payment shall be per the terms of your Provider Agreement and the Member’s benefit plan.

All services performed must be within the scope of the provider’s license. The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify Regence BlueShield if you have questions

concerning any code that may or may not be included on this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack thereof.

Effective 7/1/2017 RBS Metro Dental 1

Click the Bookmarks Tab to see fee schedules for previous effective dates

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2161 Amalgam - four or more surfaces, primary or permanent $250 $250 $175

D2330 Resin-based composite - one surface, anterior $157 $157 $110

D2331 Resin- based composite - two surfaces, anterior $200 $200 $140

D2332 Resin-based composite - three surfaces, anterior $245 $245 $172

D2335Resin-based composite - four or more surfaces involving incisal

angle (anterior)$285 $285 $200

D2390 Resin-based composite crown - anterior $285 $285 $200

D2391 Resin-based composite - one surface, posterior $173 $173 $121

D2392 Resin-based composite - two surfaces, posterior $232 $232 $162

D2393 Resin-based composite - three surfaces, posterior $285 $285 $200

D2394 Resin-based composite - four or more surfaces, posterior $318 $318 $223

D2510 Inlay - metallic - one surface $580 $580 $406

D2520 Inlay - metallic - two surfaces $657 $657 $460

D2530 Inlay - metallic - three or more surfaces $882 $882 $617

D2542 Onlay - metallic - two surfaces $632 $632 $442

D2543 Onlay - metallic - three surfaces $917 $917 $642

D2544 Onlay - metallic - four or more surfaces $1,001 $1,001 $701

D2610 Inlay - porcelain/ceramic - one surface $580 $580 $406

D2620 Inlay - porcelain/ceramic - two surfaces $664 $664 $465

D2630 Inlay - porcelain/ceramic - three or more surfaces $808 $808 $566

D2642 Onlay - porcelain/ceramic - two surfaces $683 $683 $478

D2643 Onlay - porcelain/ceramic - three surfaces $973 $973 $681

D2644 Onlay - porcelain/ceramic - four or more surfaces $1,066 $1,066 $746

D2650 Inlay - resin-based composite - one surface $556 $556 $389

D2651 Inlay - resin based composite - two surfaces $606 $606 $424

D2652 Inlay- resin based composite - three or more surfaces $657 $657 $460

D2662 Onlay - resin based composite - two surfaces $632 $632 $442

D2663 Onlay - resin based composite - three surfaces $742 $742 $519

D2664 Onlay - resin based composite - four or more surfaces $816 $816 $571

D2710 Crown - resin-based composite (indirect) $333 $333 $233

D2712 Crown - 3/4 resin-based composite (indirect) $1,001 $1,001 $701

D2720 Crown - resin with high noble metal $1,006 $1,006 $704

D2721 Crown - resin with predominantly base metal $1,001 $1,001 $701

D2722 Crown - resin with noble metal $1,001 $1,001 $701

D2740 Crown - porcelain/ceramic substrate $1,200 $1,200 $840

D2750 Crown - porcelain fused to high noble metal $1,142 $1,142 $799

D2751 Crown - porcelain fused to predominantly base metal $1,001 $1,001 $701

D2752 Crown - porcelain fused to noble metal $1,033 $1,033 $723

D2780 Crown - 3/4 cast high noble metal $1,006 $1,006 $704

D2781 Crown - 3/4 cast predominately base metal $1,001 $1,001 $701

D2782 Crown - 3/4 cast noble metal $1,001 $1,001 $701

D2783 Crown - 3/4 porcelain/ceramic $1,006 $1,006 $704

D2790 Crown - full cast high noble metal $1,066 $1,066 $746

D2791 Crown - full cast predominantly base metal $1,001 $1,001 $701

D2792 Crown - full cast noble metal $1,006 $1,006 $704

D2794 Crown - titanium $1,051 $1,051 $736

D2910Re-cement or re-bond inlay, onlay, veneer or partial coverage

restoration$79 $79 $55

D2915Re-cement or re-bond indirectly fabricated or prefabricated post

and core$76 $76 $53

D2920 Re-cement or re-bond crown $84 $84 $59

D2921 Reattachment of tooth fragment, incisal edge or cusp $282 $282 $197

D2930 Prefabricated stainless steel crown - primary tooth $229 $229 $160

D2931 Prefabricated stainless steel crown - permanent tooth $232 $232 $162

D2932 Prefabricated resin crown $218 $218 $153

D2933 Prefab stainless steel crown with resin window $232 $232 $162

D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $232 $232 $162

D2940 Protective Restoration $84 $84 $59

D2941 Interim therapeutic restoration – primary dentition $81 $81 $57

D2949 Restorative foundation for an indirect restoration $207 $207 $145

D2950 Core buildup, including any pins when required $217 $217 $152

D2952 Post and core in addition to crown, indirectly fabricated $340 $340 $238

D2954 Prefabricated post and core in addition to crown $276 $276 $193

D2955 Post removal $253 $253 $177

Effective 7/1/2017 RBS Metro Dental 2

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CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2957 Each additional prefabricated post - same tooth $113 $113 $79

D2960 Labial veneer (resin laminate) – chairside $723 $723 $506

D2961 Labial veneer (resin laminate) – laboratory $820 $820 $574

D2962 Labial veneer (porcelain laminate) – laboratory $891 $891 $624

D2971Additional procedures to construct new crown under existing

partial denture framework$101 $101 $71

D2975 Coping $253 $253 $177

D2980 Crown repair necessitated by restorative material failure $152 $152 $106

D2990 Resin infiltration of incipient smooth surface lesions $61 $61 $43

D3110 Pulp cap - direct (excluding final restoration) $64 $74 $45

D3220

Therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application of

medicament

$145 $167 $102

D3221 Pulpal debridement, primary and permanent teeth $149 $171 $104

D3222Partial pulpotomy for apexogenesis - permanent tooth with

incomplete root development$126 $145 $88

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth $168 $193 $118

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth $228 $262 $160

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $657 $920 $460

D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $783 $1,071 $548

D3330 Endodontic therapy, molar (excluding final restoration) $944 $1,340 $661

D3331 Treatment of root canal obstruction; non-surgical access $113 $130 $79

D3332Incomplete endodontic therapy; inoperable, unrestorable or

fractured tooth$284 $327 $199

D3333 Internal root repair of perforation defects $354 $407 $248

D3346 Retreatment of previous root canal therapy - anterior $709 $950 $496

D3347 Retreatment of previous root canal therapy - bicuspid $828 $1,150 $580

D3348 Retreatment of previous root canal therapy - molar $1,066 $1,400 $746

D3351Apexification/recalcification - initial visit (apical closure/calcific

repair of perforations, root resorption, etc.)$177 $250 $124

D3352 Apexification/recalcification - interim mediation replacement $51 $59 $36

D3353

Apexification/recalcification - final visit (includes completed root

canal therapy - apical closure/calcific repair of perforations, root

resorption, etc.)

$217 $262 $152

D3355 Pulpal regeneration – initial visit $177 $250 $124

D3356 Pulpal regeneration – interim medication replacement $51 $59 $36

D3357 Pulpal regeneration – completion of treatment $217 $262 $152

D3410 Apicoectomy - anterior $552 $950 $386

D3421 Apicoectomy - bicuspid (first root) $552 $950 $386

D3425 Apicoectomy - molar (first root) $552 $950 $386

D3426 Apicoectomy (each additional root) $206 $305 $144

D3427 Periradicular surgery without apicoectomy $189 $325 $132

D3428Bone graft in conjunction with periradicular surgery – per tooth,

single site$371 $427 $260

D3429Bone graft in conjunction with periradicular surgery – each

additional contiguous tooth in the same surgical site$244 $281 $171

D3430 Retrograde filling - per root $155 $203 $109

D3431Biologic materials to aid in soft and osseous tissue regeneration in

conjunction with periradicular surgery$208 $310 $146

D3432Guided tissue regeneration, resorbable barrier, per site, in

conjunction with periradicular surgery$215 $247 $151

D3450 Root amputation - per root $244 $281 $171

D3470 Intentional reimplantation (including necessary splinting) $495 $569 $347

D3920Hemisection (including any root removal), not including root canal

therapy$387 $445 $271

D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant$387 $567 $271

D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or

tooth bounded spaces per quadrant$177 $204 $124

Effective 7/1/2017 RBS Metro Dental 3

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D4240Gingival flap procedure, including root planning - four or more

contiguous teeth or tooth bounded spaces per quadrant$631 $726 $442

D4241Gingival flap procedure, including root planning - one to three

contiguous teeth or tooth bounded spaces per quadrant$354 $407 $248

D4245 Apically positioned flap $482 $645 $337

D4249 Clinical crown lengthening - hard tissue $626 $875 $438

D4260

Osseous surgery (including elevation of full thickness flap and

closure) - four or more contiguous teeth or tooth bounded spaces

per quadrant

$1,010 $1,400 $707

D4261

Osseous surgery (including elevation of full thickness flap and

closure) - one to three contiguous teeth or tooth bounded spaces

per quadrant

$707 $1,150 $495

D4263 Bone replacement graft - first site in quadrant $371 $427 $260

D4264 Bone replacement graft - each additional site in quadrant $244 $281 $171

D4265 Biologic materials to aid in soft and osseous tissue regeneration $208 $310 $146

D4266 Guided tissue regeneration - resorbable barrier, per site $318 $446 $223

D4267Guided tissue regeneration - nonresorbable barrier, per site

(includes membrane removal)$215 $280 $151

D4268 Surgical revision procedure, per tooth $207 $246 $145

D4270 Pedicle soft tissue graft procedure $643 $823 $450

D4273

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) first tooth, implant, or edentulous tooth

position in graft

$808 $929 $566

D4274Distal or proximal wedge procedure (when not performed in

conjunction with surgical procedures in the same anatomical area)$386 $444 $270

D4275

Non-autogenous connective tissue graft (including recipient site

and donor material) first tooth, implant, or edentulous tooth

position in graft

$636 $1,005 $445

D4276 Combined connective tissue and double pedicle graft, per tooth $449 $735 $314

D4277

Free soft tissue graft procedure (including recipient and donor

surgical sites) first tooth, implant or edentulous tooth position in

graft

$808 $995 $566

D4278

Free soft tissue graft procedure (including recipient and donor

surgical sites) each additional contiguous tooth, implant or

edentulous tooth position in same graft site

$398 $515 $279

D4283

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) – each additional contiguous tooth, implant

or edentulous tooth position in same graft site

$606 $697 $424

D4285

Non-autogenous connective tissue graft procedure (including

recipient surgical site and donor material) – each additional

contiguous tooth, implant or edentulous tooth position in same

graft site

$478 $754 $335

D4341Periodontal scaling and root planning - four or more teeth per

quadrant $207 $282 $145

D4342Periodontal scaling and root planning - one to three teeth per

quadrant$131 $151 $92

D4346Scaling in presence of generalized moderate or severe gingival

inflamation -- full mouth, after oral evaluation$162 $186 $113

D4355Full mouth debridement to enable comprehensive evaluation and

diagnosis$128 $147 $90

D4910 Periodontal maintenance $162 $186 $113

D4920Unscheduled dressing change (by someone other than treating

dentist)$32 $37 $22

D5110 Complete denture - maxillary $1,288 $1,481 $902

D5120 Complete denture - mandibular $1,288 $1,481 $902

D5130 Immediate denture - maxillary $1,288 $1,481 $902

D5140 Immediate denture - mandibular $1,288 $1,481 $902

D5211Maxillary partial denture - resin base (including any conventional

clasps, rests and teeth)$1,368 $1,573 $958

Effective 7/1/2017 RBS Metro Dental 4

NON-PAR

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CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D5212Mandibular partial denture - resin base (including any conventional

clasps, rests and teeth)$1,368 $1,573 $958

D5213Maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)$1,374 $1,580 $962

D5214Mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)$1,374 $1,580 $962

D5221Immediate maxillary partial denture – resin base (including any

conventional clasps, rests and teeth)$1,368 $1,573 $958

D5222Immediate mandibular partial denture – resin base (including any

conventional clasps, rests and teeth)$1,368 $1,573 $958

D5223

Immediate maxillary partial denture – cast metal framework with

resin denture bases (including any conventional clasps, rests and

teeth)

$1,374 $1,580 $962

D5224

Immediate mandibular partial denture – cast metal framework

with resin denture bases (including any conventional clasps, rests

and teeth)

$1,374 $1,580 $962

D5225Maxillary partial denture - flexible base (including any clasps, rests

and teeth)$1,368 $1,573 $958

D5226Mandibular partial denture - flexible base (including any clasps,

rests and teeth)$1,368 $1,573 $958

D5281Removable unilateral partial denture - one piece cast metal

(including clasps and teeth)$859 $988 $601

D5410 Adjust complete denture - maxillary $80 $92 $56

D5411 Adjust complete denture - mandibular $80 $92 $56

D5421 Adjust partial denture - maxillary $66 $76 $46

D5422 Adjust partial denture - mandibular $66 $76 $46

D5510 Repair broken complete denture base $116 $133 $81

D5520 Replace missing or broken teeth - complete denture (each tooth) $116 $133 $81

D5610 Repair resin denture base $120 $138 $84

D5620 Repair cast framework $185 $213 $130

D5630 Repair or replace broken clasp - per tooth $135 $155 $95

D5640 Replace broken teeth - per tooth $114 $131 $80

D5650 Add tooth to existing partial denture $162 $186 $113

D5660 Add clasp to existing partial denture - per tooth $164 $189 $115

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $714 $821 $500

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $714 $821 $500

D5710 Rebase complete maxillary denture $473 $544 $331

D5711 Rebase complete mandibular denture $473 $544 $331

D5720 Rebase maxillary partial denture $473 $544 $331

D5721 Rebase mandibular partial denture $473 $544 $331

D5730 Reline complete maxillary denture (chairside) $259 $298 $181

D5731 Reline complete mandibular denture (chairside) $259 $298 $181

D5740 Reline maxillary partial denture (chairside) $226 $260 $158

D5741 Reline mandibular partial denture (chairside) $226 $260 $158

D5750 Reline complete maxillary denture (laboratory) $390 $449 $273

D5751 Reline complete mandibular denture (laboratory) $390 $449 $273

D5760 Reline maxillary partial denture (laboratory) $368 $423 $258

D5761 Reline mandibular partial denture (laboratory) $368 $423 $258

D5850 Tissue conditioning, maxillary $91 $105 $64

D5851 Tissue conditioning, mandibular $91 $105 $64

D5863 Overdenture – complete maxillary $1,275 $1,469 $893

D5864 Overdenture – partial maxillary $1,368 $1,573 $958

D5865 Overdenture – complete mandibular $1,275 $1,469 $893

D5866 Overdenture – partial mandibular $1,368 $1,573 $958

D6010 Surgical placement of implant body: endosteal implant $2,062 $2,371 $1,443

D6055 Connecting bar – implant supported or abutment supported $633 $728 $443

D6056 Prefabricated abutment – includes modification and placement $424 $488 $297

D6057 Custom fabricated abutment - includes placement $677 $779 $474

Effective 7/1/2017 RBS Metro Dental 5

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6058 Abutment supported porcelain/ceramic crown $1,200 $1,380 $840

D6059Abutment supported porcelain fused to metal crown (high noble

metal)$1,200 $1,380 $840

D6060Abutment supported porcelain fused to metal crown

(predominantly base metal)$1,001 $1,151 $701

D6061 Abutment supported porcelain fused to metal crown (noble metal) $1,033 $1,188 $723

D6062 Abutment supported cast metal crown (high noble metal) $1,066 $1,226 $746

D6063 Abutment supported cast metal crown (predominantly base metal) $1,001 $1,151 $701

D6064 Abutment supported cast metal crown (noble metal) $1,006 $1,157 $704

D6065 Implant supported porcelain/ceramic crown $1,200 $1,380 $840

D6066Implant supported porcelain fused to metal crown (titanium,

titanium allow, high noble metal)$1,200 $1,380 $840

D6067Implant supported metal crown (titanium, titanium alloy, high

noble metal)$1,066 $1,226 $746

D6068 Abutment supported retainer for porcelain/ceramic FPD $1,200 $1,380 $840

D6069Abutment supported retainer for porcelain fused to metal FPD

(high noble metal)$1,200 $1,380 $840

D6070Abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)$1,001 $1,151 $701

D6071Abutment supported retainer for porcelain fused to metal FPD

(noble metal)$1,033 $1,188 $723

D6072 Abutment supported retainer for cast metal FPD (high noble metal) $1,066 $1,226 $746

D6073Abutment supported retainer for cast metal FPD (predominantly

base metal)$1,001 $1,151 $701

D6074 Abutment supported retainer for cast metal FPD (noble metal) $1,006 $1,157 $704

D6075 Implant supported retainer for ceramic FPD $1,200 $1,380 $840

D6076Implant supported retainer porcelain fused to metal FPD (titanium,

titanium alloy, or high noble metal)$1,200 $1,380 $840

D6081

Scaling and debridement in the presence of inflammation or

mucositis of a single implant, including cleaning of the implant

surfaces, without flap entry and closure

$131 $151 $92

D6085 Provisional implant crown $475 $546 $333

D6090 Repair implant supported prosthesis, by report $429 $493 $300

D6092 Re-cement or re-bond implant/abutment supported crown $77 $89 $54

D6093Re-cement or re-bond implant/abutment supported fixed partial

denture$107 $123 $75

D6094 Abutment supported crown (titanium) $1,051 $1,209 $736

D6095 Repair implant abutment, by report $253 $291 $177

D6100 Implant removal, by report $212 $244 $148

D6110Implant/abutment supported removable denture for edentulous

arch - maxillary$1,288 $1,481 $902

D6111Implant/abutment supported removable denture for edentulous

arch – mandibular$1,288 $1,481 $902

D6112Implant/abutment supported removable denture for partially

edentulous arch – maxillary$1,368 $1,573 $958

D6113Implant /abutment supported removable denture for partially

edentulous arch - mandibular$1,368 $1,573 $958

D6194 Abutment supported retainer crown for cast metal FPD (titanium) $1,051 $1,209 $736

D6205 Pontic - indirect resin based composite $404 $465 $283

D6210 Pontic - cast high noble metal $951 $1,094 $666

D6211 Pontic - cast predominantly base metal $951 $1,094 $666

D6212 Pontic - cast noble metal $951 $1,094 $666

D6214 Pontic - titanium $951 $1,094 $666

D6240 Pontic - porcelain fused to high noble metal $960 $1,104 $672

D6241 Pontic - porcelain fused to predominantly base metal $951 $1,094 $666

D6242 Pontic - porcelain fused to noble metal $960 $1,104 $672

D6245 Pontic - porcelain/ceramic $960 $1,104 $672

D6250 Pontic - resin with high noble metal $951 $1,094 $666

D6251 Pontic - resin with predominantly base metal $951 $1,094 $666

Effective 7/1/2017 RBS Metro Dental 6

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6252 Pontic - resin with noble metal $951 $1,094 $666

D6545 Retainer- cast metal for resin bonded fixed prosthesis $505 $581 $354

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $849 $976 $594

D6549 Resin retainer-for resin bonded fixed prosthesis $500 $575 $350

D6608 Onlay - porcelain/ceramic, two surfaces $632 $727 $442

D6609 Onlay - porcelain/ceramic, three or more surfaces $1,038 $1,194 $727

D6610 Onlay - cast high noble metal, two surfaces $593 $682 $415

D6611 Onlay - cast high noble metal, three or more surfaces $714 $821 $500

D6612 Onlay - cast predominantly base metal, two surfaces $593 $682 $415

D6613 Onlay - cast predominantly base metal, three or more surfaces $714 $821 $500

D6614 Onlay - cast noble metal, two surfaces $593 $682 $415

D6615 Onlay - cast noble metal, three or more surfaces $714 $821 $500

D6624 Inlay - titanium $1,001 $1,151 $701

D6634 Onlay - titanium $991 $1,140 $694

D6710 Crown - indirect resin based composite $1,001 $1,151 $701

D6720 Crown - resin with high noble metal $1,001 $1,151 $701

D6721 Crown - resin with predominantly base metal $1,001 $1,151 $701

D6722 Crown - resin with noble metal $1,001 $1,151 $701

D6740 Crown - porcelain/ceramic $1,200 $1,380 $840

D6750 Crown - porcelain fused to high noble metal $1,142 $1,313 $799

D6751 Crown - porcelain fused to predominantly base metal $1,001 $1,151 $701

D6752 Crown - porcelain fused to noble metal $1,033 $1,188 $723

D6780 Crown - 3/4 cast high noble metal $1,006 $1,157 $704

D6781 Crown - 3/4 cast predominantly base metal $1,001 $1,151 $701

D6782 Crown - 3/4 cast noble metal $1,001 $1,151 $701

D6783 Crown - 3/4 porcelain/ceramic $1,006 $1,157 $704

D6790 Crown - full cast high noble metal $1,066 $1,226 $746

D6791 Crown - full cast predominantly base metal $1,001 $1,151 $701

D6792 Crown - full cast noble metal $1,006 $1,157 $704

D6794 Crown - titanium $1,051 $1,209 $736

D6930 Re-cement or re-bond fixed partial denture $126 $145 $88

D6980Fixed partial denture repair necessitated by restorative material

failure$191 $220 $134

D7111 Extraction, coronal remnants - deciduous tooth $107 $123 $75

D7140Extraction, erupted tooth or exposed root (elevation and/or

forceps removal)$139 $160 $97

D7210

Surgical removal of erupted tooth requiring removal of bone

and/or sectioning of tooth, and including elevation of

mucoperiosteal flap if indicated

$258 $297 $181

D7220 Removal of impacted tooth - soft tissue $273 $314 $191

D7230 Removal of impacted tooth - partially bony $354 $407 $248

D7240 Removal of impacted tooth - completely bony $404 $505 $283

D7241Removal of impact tooth - completely bony, with unusual surgical

complications$429 $601 $300

D7250 Surgical removal of residual tooth roots (cutting procedure) $212 $300 $148

D7251 Coronectomy – intentional partial tooth removal $359 $450 $251

D7260 Oroantral fistula closure $480 $552 $336

D7261 Primary closure of a sinus perforation $51 $60 $36

D7270Tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth$483 $573 $338

D7280 Surgical access of an unerupted tooth $404 $530 $283

D7282 Mobilization of erupted or malpositioned tooth to aid eruption $106 $122 $74

D7285 Incisional biopsy of oral tissue - hard (bone, tooth) $343 $408 $240

D7286 Incisional biopsy of oral tissue - soft $266 $312 $186

D7290 Surgical repositioning of teeth $420 $499 $294

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $149 $171 $104

D7310Alveoloplasty in conjunction with extractions - four or more teeth

or tooth spaces, per quadrant$172 $198 $120

D7311Alveoloplasty in conjunction with extractions - one to three teeth

or tooth spaces, per quadrant$165 $197 $116

Effective 7/1/2017 RBS Metro Dental 7

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D7320Alveoloplasty not in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant$224 $258 $157

D7321Alveoloplasty not in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant$224 $258 $157

D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $545 $627 $382

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts,

muscle reattachment, revisions of soft tissue attachment and

management of hypertrophied and hyperplastic tissue)

$606 $720 $424

D7410 Excision of benign lesion up to 1.25 cm $228 $275 $160

D7411 Excision of benign lesion greater than 1.25 cm $303 $360 $212

D7412 Excision of benign lesion, complicated $354 $420 $248

D7450Removal of benign odontogenic cyst or tumor - lesion diameter up

to 1.25 cm$342 $500 $239

D7451Removal of benign odontogenic cyst or tumor - lesion diameter

greater than 1.25 cm$521 $800 $365

D7465 Destruction of lesion(s) by physical or chemical method, by report $80 $92 $56

D7471 Removal of lateral exostosis (maxilla or mandible) $338 $389 $237

D7472 Removal of torus palatinus $338 $389 $237

D7473 Removal of torus mandibularis $369 $600 $258

D7485 Surgical reduction of osseous tuberosity $338 $389 $237

D7510 Incision and drain of abscess - intraoral soft tissue $150 $200 $105

D7511Incision and drainage of abscess - intraoral soft tissue -

complicated (includes drainage of multiple fascial spaces)$490 $564 $343

D7530Removal of foreign body from mucosa, skin, or subcutaneous

alveolar tissue$159 $183 $111

D7540Removal of reaction producing foreign bodies, musculoskeletal

system$132 $157 $92

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $227 $270 $159

D7560Maxillary sinusotomy for removal of tooth fragment or foreign

body$442 $525 $309

D7880 Occlusal orthotic device, by report $495 $569 $347

D7881 Occlusal orthotic device adjustment $80 $92 $56

D7910 Suture of recent small wounds up to 5 cm $208 $239 $146

D7911 Complicated suture - up to 5 cm $295 $339 $207

D7912 Complicated suture - greater than 5 cm $354 $407 $248

D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or

maxilla – autogenous or nonautogenous, by report$1,278 $1,470 $895

D7953 Bone replacement graft for ridge preservation - per site $308 $400 $216

D7960Frenulectomy – also known as frenectomy or frenotomy - separate

procedure not incidental to another$404 $465 $283

D7963 Frenuloplasty $180 $266 $126

D7970 Excision of hyperplastic tissue - per arch $202 $285 $141

D7971 Excision of periocoronal gingiva $162 $186 $113

D7972 Surgical reduction of fibrous tuberosity $338 $389 $237

D9110 Palliative (emergent) treatment of dental pain - minor procedure $126 $126 $88

D9120 Fixed partial denture sectioning $157 $157 $110

D9223 Deep sedation/general anesthesia – each 15 minute increment $146 $174 $102

D9243Intravenous moderate (conscious) sedation/analgesia – each 15

minute increment$113 $113 $79

D9248 Non-intravenous conscious sedation $81 $81 $57

D9410 House/extended care facility call $68 $68 $48

D9420 Hospital or ambulatory surgical center call $73 $73 $51

D9430Office visit for observation (during regularly scheduled hours) - no

other services performed$36 $36 $25

D9440 Office visit - after regularly scheduled hours $102 $102 $71

D9940 Occlusal guard, by report $480 $480 $336

D9942 Repair and/or reline of occlusal guard $53 $53 $37

D9943 Occlusal guard adjustment $80 $91 $56

Effective 7/1/2017 RBS Metro Dental 8

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

D0120 Periodic oral evaluation - established patient $57 $57 $40

D0140 Limited oral evaluation - problem focused $69 $90 $48

D0145Oral evaluation for patient under three years of age and counseling

with primary caregiver$56 $56 $39

D0150 Comprehensive oral evaluation - new or established patient $80 $80 $56

D0160Detailed and extensive oral evaluation - problem focused, by

report$125 $125 $88

D0170Re-evaluation - limited, problem focused (established patient; not

post-operative visit)$66 $66 $46

D0180 Comprehensive periodontal evaluation - new or established patient $97 $168 $68

D0210 Intraoral - complete series (including bitewings) $123 $123 $86

D0220 Intraoral - periapical first radiographic image $26 $26 $18

D0230 Intraoral - periapical each additional radiographic image $20 $20 $14

D0240 Intraoral - occlusal radiographic image $28 $28 $20

D0250Extraoral – 2D projection radiographic image created using a

stationary radiation source, and detector$60 $60 $42

D0251 Extraoral - posterior dental radiographic image $26 $26 $18

D0270 Bitewing - single radiographic image $20 $20 $14

D0272 Bitewings - two radiographic images $41 $41 $29

D0273 Bitewings - three radiographic images $47 $47 $33

D0274 Bitewings - four radiographic images $60 $60 $42

D0277 Vertical bitewings - 7 to 8 radiographic images $89 $89 $62

D0320 Temporomandibular joint arthrogram, including injection $40 $40 $28

D0330 Panoramic radiographic image $98 $98 $69

D03402D cephalometric radiographic image – acquisition, measurement

and analysis$60 $60 $42

D0460 Pulp vitality tests $39 $39 $27

D1110 Prophylaxis – adult $111 $111 $78

D1120 Prophylaxis - child $72 $72 $50

D1206 Topical fluoride varnish $37 $37 $26

D1208 Topical application of fluoride – excluding varnish $37 $37 $26

D1330 Oral hygiene instructions $56 $56 $39

D1351 Sealant - per tooth $48 $48 $34

D1352Preventive resin restoration in a moderate to high caries risk

patient - permanent tooth$72 $72 $50

D1510 Space maintainer - fixed - unilateral $300 $300 $210

D1515 Space maintainer - fixed - bilateral $402 $402 $281

D1520 Space maintainer - removable – unilateral $280 $280 $196

D1525 Space maintainer - removable - bilateral $395 $395 $277

D1550 Re-cement or re-bond space maintainer $53 $53 $37

D1575 Distal shoe space maintainer -- fixed / unilateral $300 $300 $210

D1555 Removal of fixed space maintainer $35 $35 $25

D2140 Amalgam - one surface, primary or permanent $125 $125 $88

D2150 Amalgam - two surfaces, primary or permanent $181 $181 $127

D2160 Amalgam - three surfaces, primary or permanent $217 $217 $152

PAR ALLOWED AMOUNTS

Confidential and Proprietary - Regence BlueShieldParticipating Dental Reimbursement Rates

Effective January 1, 2017

All published Regence BlueShield Administrative Guidelines apply.Payment shall be per the terms of your Provider Agreement and the Member’s benefit plan.

All services performed must be within the scope of the provider’s license. The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify Regence BlueShield if you have questions

concerning any code that may or may not be included on this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack thereof.

Effective 1/1/2017 RBS Metro Dental 1

Click the Bookmarks Tab to see fee schedules for previous effective dates

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2161 Amalgam - four or more surfaces, primary or permanent $248 $248 $174

D2330 Resin-based composite - one surface, anterior $155 $155 $109

D2331 Resin- based composite - two surfaces, anterior $198 $198 $139

D2332 Resin-based composite - three surfaces, anterior $243 $243 $170

D2335Resin-based composite - four or more surfaces involving incisal

angle (anterior)$282 $282 $197

D2390 Resin-based composite crown - anterior $282 $282 $197

D2391 Resin-based composite - one surface, posterior $171 $171 $120

D2392 Resin-based composite - two surfaces, posterior $230 $230 $161

D2393 Resin-based composite - three surfaces, posterior $282 $282 $197

D2394 Resin-based composite - four or more surfaces, posterior $315 $315 $221

D2510 Inlay - metallic - one surface $574 $574 $402

D2520 Inlay - metallic - two surfaces $650 $650 $455

D2530 Inlay - metallic - three or more surfaces $873 $873 $611

D2542 Onlay - metallic - two surfaces $626 $626 $438

D2543 Onlay - metallic - three surfaces $908 $908 $636

D2544 Onlay - metallic - four or more surfaces $991 $991 $694

D2610 Inlay - porcelain/ceramic - one surface $574 $574 $402

D2620 Inlay - porcelain/ceramic - two surfaces $657 $657 $460

D2630 Inlay - porcelain/ceramic - three or more surfaces $800 $800 $560

D2642 Onlay - porcelain/ceramic - two surfaces $676 $676 $473

D2643 Onlay - porcelain/ceramic - three surfaces $963 $963 $674

D2644 Onlay - porcelain/ceramic - four or more surfaces $1,055 $1,055 $739

D2650 Inlay - resin-based composite - one surface $550 $550 $385

D2651 Inlay - resin based composite - two surfaces $600 $600 $420

D2652 Inlay- resin based composite - three or more surfaces $650 $650 $455

D2662 Onlay - resin based composite - two surfaces $626 $626 $438

D2663 Onlay - resin based composite - three surfaces $735 $735 $515

D2664 Onlay - resin based composite - four or more surfaces $808 $808 $566

D2710 Crown - resin-based composite (indirect) $330 $330 $231

D2712 Crown - 3/4 resin-based composite (indirect) $991 $991 $694

D2720 Crown - resin with high noble metal $996 $996 $697

D2721 Crown - resin with predominantly base metal $991 $991 $694

D2722 Crown - resin with noble metal $991 $991 $694

D2740 Crown - porcelain/ceramic substrate $1,078 $1,078 $755

D2750 Crown - porcelain fused to high noble metal $1,066 $1,066 $746

D2751 Crown - porcelain fused to predominantly base metal $991 $991 $694

D2752 Crown - porcelain fused to noble metal $1,023 $1,023 $716

D2780 Crown - 3/4 cast high noble metal $996 $996 $697

D2781 Crown - 3/4 cast predominately base metal $991 $991 $694

D2782 Crown - 3/4 cast noble metal $991 $991 $694

D2783 Crown - 3/4 porcelain/ceramic $996 $996 $697

D2790 Crown - full cast high noble metal $1,055 $1,055 $739

D2791 Crown - full cast predominantly base metal $991 $991 $694

D2792 Crown - full cast noble metal $996 $996 $697

D2794 Crown - titanium $1,041 $1,041 $729

D2910Re-cement or re-bond inlay, onlay, veneer or partial coverage

restoration$78 $78 $55

D2915Re-cement or re-bond indirectly fabricated or prefabricated post

and core$75 $75 $53

D2920 Re-cement or re-bond crown $83 $83 $58

D2921 Reattachment of tooth fragment, incisal edge or cusp $279 $279 $195

D2930 Prefabricated stainless steel crown - primary tooth $227 $227 $159

D2931 Prefabricated stainless steel crown - permanent tooth $230 $230 $161

D2932 Prefabricated resin crown $216 $216 $151

D2933 Prefab stainless steel crown with resin window $230 $230 $161

D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $230 $230 $161

D2940 Protective Restoration $83 $83 $58

D2941 Interim therapeutic restoration – primary dentition $80 $80 $56

D2949 Restorative foundation for an indirect restoration $205 $205 $144

D2950 Core buildup, including any pins when required $215 $215 $151

D2952 Post and core in addition to crown, indirectly fabricated $337 $337 $236

D2954 Prefabricated post and core in addition to crown $273 $273 $191

D2955 Post removal $250 $250 $175

Effective 1/1/2017 RBS Metro Dental 2

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2957 Each additional prefabricated post - same tooth $112 $112 $78

D2960 Labial veneer (resin laminate) – chairside $716 $716 $501

D2961 Labial veneer (resin laminate) – laboratory $812 $812 $568

D2962 Labial veneer (porcelain laminate) – laboratory $882 $882 $617

D2971Additional procedures to construct new crown under existing

partial denture framework$100 $100 $70

D2975 Coping $250 $250 $175

D2980 Crown repair necessitated by restorative material failure $150 $150 $105

D2990 Resin infiltration of incipient smooth surface lesions $60 $60 $42

D3110 Pulp cap - direct (excluding final restoration) $63 $72 $44

D3220

Therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application of

medicament

$144 $166 $101

D3221 Pulpal debridement, primary and permanent teeth $148 $170 $104

D3222Partial pulpotomy for apexogenesis - permanent tooth with

incomplete root development$125 $144 $88

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth $166 $191 $116

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth $226 $260 $158

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $650 $920 $455

D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $775 $1,071 $543

D3330 Endodontic therapy, molar (excluding final restoration) $935 $1,340 $655

D3331 Treatment of root canal obstruction; non-surgical access $112 $129 $78

D3332Incomplete endodontic therapy; inoperable, unrestorable or

fractured tooth$281 $323 $197

D3333 Internal root repair of perforation defects $350 $403 $245

D3346 Retreatment of previous root canal therapy - anterior $702 $950 $491

D3347 Retreatment of previous root canal therapy - bicuspid $820 $1,150 $574

D3348 Retreatment of previous root canal therapy - molar $1,055 $1,400 $739

D3351Apexification/recalcification - initial visit (apical closure/calcific

repair of perforations, root resorption, etc.)$175 $250 $123

D3352 Apexification/recalcification - interim mediation replacement $50 $58 $35

D3353

Apexification/recalcification - final visit (includes completed root

canal therapy - apical closure/calcific repair of perforations, root

resorption, etc.)

$215 $262 $151

D3355 Pulpal regeneration – initial visit $175 $250 $123

D3356 Pulpal regeneration – interim medication replacement $50 $58 $35

D3357 Pulpal regeneration – completion of treatment $215 $262 $151

D3410 Apicoectomy - anterior $547 $950 $383

D3421 Apicoectomy - bicuspid (first root) $547 $950 $383

D3425 Apicoectomy - molar (first root) $547 $950 $383

D3426 Apicoectomy (each additional root) $204 $305 $143

D3427 Periradicular surgery without apicoectomy $187 $325 $131

D3428Bone graft in conjunction with periradicular surgery – per tooth,

single site$367 $422 $257

D3429Bone graft in conjunction with periradicular surgery – each

additional contiguous tooth in the same surgical site$242 $278 $169

D3430 Retrograde filling - per root $153 $203 $107

D3431Biologic materials to aid in soft and osseous tissue regeneration in

conjunction with periradicular surgery$206 $310 $144

D3432Guided tissue regeneration, resorbable barrier, per site, in

conjunction with periradicular surgery$213 $245 $149

D3450 Root amputation - per root $242 $278 $169

D3470 Intentional reimplantation (including necessary splinting) $490 $564 $343

D3920Hemisection (including any root removal), not including root canal

therapy$383 $440 $268

D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant$383 $567 $268

D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or

tooth bounded spaces per quadrant$175 $201 $123

Effective 1/1/2017 RBS Metro Dental 3

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D4240Gingival flap procedure, including root planning - four or more

contiguous teeth or tooth bounded spaces per quadrant$625 $719 $438

D4241Gingival flap procedure, including root planning - one to three

contiguous teeth or tooth bounded spaces per quadrant$350 $403 $245

D4245 Apically positioned flap $477 $645 $334

D4249 Clinical crown lengthening - hard tissue $620 $875 $434

D4260

Osseous surgery (including elevation of full thickness flap and

closure) - four or more contiguous teeth or tooth bounded spaces

per quadrant

$1,000 $1,400 $700

D4261

Osseous surgery (including elevation of full thickness flap and

closure) - one to three contiguous teeth or tooth bounded spaces

per quadrant

$700 $1,150 $490

D4263 Bone replacement graft - first site in quadrant $367 $422 $257

D4264 Bone replacement graft - each additional site in quadrant $242 $278 $169

D4265 Biologic materials to aid in soft and osseous tissue regeneration $206 $310 $144

D4266 Guided tissue regeneration - resorbable barrier, per site $315 $446 $221

D4267Guided tissue regeneration - nonresorbable barrier, per site

(includes membrane removal)$213 $280 $149

D4268 Surgical revision procedure, per tooth $205 $246 $144

D4270 Pedicle soft tissue graft procedure $637 $823 $446

D4273

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) first tooth, implant, or edentulous tooth

position in graft

$800 $920 $560

D4274Distal or proximal wedge procedure (when not performed in

conjunction with surgical procedures in the same anatomical area)$382 $439 $267

D4275

Non-autogenous connective tissue graft (including recipient site

and donor material) first tooth, implant, or edentulous tooth

position in graft

$630 $1,005 $441

D4276 Combined connective tissue and double pedicle graft, per tooth $445 $735 $312

D4277

Free soft tissue graft procedure (including recipient and donor

surgical sites) first tooth, implant or edentulous tooth position in

graft

$800 $995 $560

D4278

Free soft tissue graft procedure (including recipient and donor

surgical sites) each additional contiguous tooth, implant or

edentulous tooth position in same graft site

$394 $515 $276

D4283

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) – each additional contiguous tooth, implant

or edentulous tooth position in same graft site

$600 $690 $420

D4285

Non-autogenous connective tissue graft procedure (including

recipient surgical site and donor material) – each additional

contiguous tooth, implant or edentulous tooth position in same

graft site

$473 $754 $331

D4341Periodontal scaling and root planning - four or more teeth per

quadrant $205 $282 $144

D4342Periodontal scaling and root planning - one to three teeth per

quadrant$130 $150 $91

D4346Scaling in presence of generalized moderate or severe gingival

inflamation -- full mouth, after oral evaluation$160 $184 $112

D4355Full mouth debridement to enable comprehensive evaluation and

diagnosis$127 $146 $89

D4910 Periodontal maintenance $160 $184 $112

D4920Unscheduled dressing change (by someone other than treating

dentist)$32 $37 $22

D5110 Complete denture - maxillary $1,275 $1,469 $893

D5120 Complete denture - mandibular $1,275 $1,469 $893

D5130 Immediate denture - maxillary $1,275 $1,469 $893

D5140 Immediate denture - mandibular $1,275 $1,469 $893

D5211Maxillary partial denture - resin base (including any conventional

clasps, rests and teeth)$1,354 $1,557 $948

Effective 1/1/2017 RBS Metro Dental 4

NON-PAR

ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D5212Mandibular partial denture - resin base (including any conventional

clasps, rests and teeth)$1,354 $1,557 $948

D5213Maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)$1,360 $1,564 $952

D5214Mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)$1,360 $1,564 $952

D5221Immediate maxillary partial denture – resin base (including any

conventional clasps, rests and teeth)$1,354 $1,557 $948

D5222Immediate mandibular partial denture – resin base (including any

conventional clasps, rests and teeth)$1,354 $1,557 $948

D5223

Immediate maxillary partial denture – cast metal framework with

resin denture bases (including any conventional clasps, rests and

teeth)

$1,360 $1,564 $952

D5224

Immediate mandibular partial denture – cast metal framework

with resin denture bases (including any conventional clasps, rests

and teeth)

$1,360 $1,564 $952

D5225Maxillary partial denture - flexible base (including any clasps, rests

and teeth)$1,354 $1,557 $948

D5226Mandibular partial denture - flexible base (including any clasps,

rests and teeth)$1,354 $1,557 $948

D5281Removable unilateral partial denture - one piece cast metal

(including clasps and teeth)$850 $978 $595

D5410 Adjust complete denture - maxillary $79 $91 $55

D5411 Adjust complete denture - mandibular $79 $91 $55

D5421 Adjust partial denture - maxillary $65 $75 $46

D5422 Adjust partial denture - mandibular $65 $75 $46

D5510 Repair broken complete denture base $115 $132 $81

D5520 Replace missing or broken teeth - complete denture (each tooth) $115 $132 $81

D5610 Repair resin denture base $119 $137 $83

D5620 Repair cast framework $183 $210 $128

D5630 Repair or replace broken clasp - per tooth $134 $154 $94

D5640 Replace broken teeth - per tooth $113 $130 $79

D5650 Add tooth to existing partial denture $160 $184 $112

D5660 Add clasp to existing partial denture - per tooth $162 $186 $113

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $707 $813 $495

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $707 $813 $495

D5710 Rebase complete maxillary denture $468 $538 $328

D5711 Rebase complete mandibular denture $468 $538 $328

D5720 Rebase maxillary partial denture $468 $538 $328

D5721 Rebase mandibular partial denture $468 $538 $328

D5730 Reline complete maxillary denture (chairside) $256 $294 $179

D5731 Reline complete mandibular denture (chairside) $256 $294 $179

D5740 Reline maxillary partial denture (chairside) $224 $258 $157

D5741 Reline mandibular partial denture (chairside) $224 $258 $157

D5750 Reline complete maxillary denture (laboratory) $386 $444 $270

D5751 Reline complete mandibular denture (laboratory) $386 $444 $270

D5760 Reline maxillary partial denture (laboratory) $364 $419 $255

D5761 Reline mandibular partial denture (laboratory) $364 $419 $255

D5850 Tissue conditioning, maxillary $90 $104 $63

D5851 Tissue conditioning, mandibular $90 $104 $63

D5863 Overdenture – complete maxillary $1,257 $1,469 $880

D5864 Overdenture – partial maxillary $1,354 $1,557 $948

D5865 Overdenture – complete mandibular $1,257 $1,469 $880

D5866 Overdenture – partial mandibular $1,354 $1,557 $948

D6010 Surgical placement of implant body: endosteal implant $2,042 $2,348 $1,429

D6055 Connecting bar – implant supported or abutment supported $627 $721 $439

D6056 Prefabricated abutment – includes modification and placement $420 $483 $294

D6057 Custom fabricated abutment - includes placement $670 $771 $469

Effective 1/1/2017 RBS Metro Dental 5

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ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6058 Abutment supported porcelain/ceramic crown $1,078 $1,241 $755

D6059Abutment supported porcelain fused to metal crown (high noble

metal)$1,066 $1,226 $746

D6060Abutment supported porcelain fused to metal crown

(predominantly base metal)$991 $1,140 $694

D6061 Abutment supported porcelain fused to metal crown (noble metal) $1,023 $1,179 $716

D6062 Abutment supported cast metal crown (high noble metal) $1,055 $1,213 $739

D6063 Abutment supported cast metal crown (predominantly base metal) $991 $1,140 $694

D6064 Abutment supported cast metal crown (noble metal) $996 $1,145 $697

D6065 Implant supported porcelain/ceramic crown $1,078 $1,240 $755

D6066Implant supported porcelain fused to metal crown (titanium,

titanium allow, high noble metal)$1,066 $1,226 $746

D6067Implant supported metal crown (titanium, titanium alloy, high

noble metal)$1,055 $1,213 $739

D6068 Abutment supported retainer for porcelain/ceramic FPD $1,078 $1,240 $755

D6069Abutment supported retainer for porcelain fused to metal FPD

(high noble metal)$1,066 $1,226 $746

D6070Abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)$991 $1,140 $694

D6071Abutment supported retainer for porcelain fused to metal FPD

(noble metal)$1,025 $1,179 $718

D6072 Abutment supported retainer for cast metal FPD (high noble metal) $1,055 $1,213 $739

D6073Abutment supported retainer for cast metal FPD (predominantly

base metal)$991 $1,140 $694

D6074 Abutment supported retainer for cast metal FPD (noble metal) $996 $1,145 $697

D6075 Implant supported retainer for ceramic FPD $1,078 $1,240 $755

D6076Implant supported retainer porcelain fused to metal FPD (titanium,

titanium alloy, or high noble metal)$1,066 $1,226 $746

D6081

Scaling and debridement in the presence of inflammation or

mucositis of a single implant, including cleaning of the implant

surfaces, without flap entry and closure

$130 $150 $91

D6085 Provisional implant crown $470 $470 $344

D6090 Repair implant supported prosthesis, by report $425 $489 $298

D6092 Re-cement or re-bond implant/abutment supported crown $76 $87 $53

D6093Re-cement or re-bond implant/abutment supported fixed partial

denture$106 $122 $74

D6094 Abutment supported crown (titanium) $991 $1,140 $694

D6095 Repair implant abutment, by report $250 $288 $175

D6100 Implant removal, by report $210 $242 $147

D6110Implant/abutment supported removable denture for edentulous

arch - maxillary$1,275 $1,469 $893

D6111Implant/abutment supported removable denture for edentulous

arch – mandibular$1,275 $1,469 $893

D6112Implant/abutment supported removable denture for partially

edentulous arch – maxillary$1,354 $1,557 $948

D6113Implant /abutment supported removable denture for partially

edentulous arch - mandibular$1,354 $1,557 $948

D6194 Abutment supported retainer crown for cast metal FPD (titanium) $1,041 $1,197 $729

D6205 Pontic - indirect resin based composite $400 $460 $280

D6210 Pontic - cast high noble metal $942 $1,083 $659

D6211 Pontic - cast predominantly base metal $942 $1,083 $659

D6212 Pontic - cast noble metal $942 $1,083 $659

D6214 Pontic - titanium $942 $1,083 $659

D6240 Pontic - porcelain fused to high noble metal $950 $1,093 $665

D6241 Pontic - porcelain fused to predominantly base metal $942 $1,083 $659

D6242 Pontic - porcelain fused to noble metal $950 $1,093 $665

D6245 Pontic - porcelain/ceramic $950 $1,093 $665

D6250 Pontic - resin with high noble metal $942 $1,083 $659

D6251 Pontic - resin with predominantly base metal $942 $1,083 $659

Effective 1/1/2017 RBS Metro Dental 6

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ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6252 Pontic - resin with noble metal $942 $1,083 $659

D6545 Retainer- cast metal for resin bonded fixed prosthesis $500 $575 $350

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $500 $976 $350

D6549 Resin retainer-for resin bonded fixed prosthesis $849 $976 $594

D6608 Onlay - porcelain/ceramic, two surfaces $626 $720 $438

D6609 Onlay - porcelain/ceramic, three or more surfaces $1,028 $1,182 $720

D6610 Onlay - cast high noble metal, two surfaces $587 $675 $411

D6611 Onlay - cast high noble metal, three or more surfaces $707 $813 $495

D6612 Onlay - cast predominantly base metal, two surfaces $587 $675 $411

D6613 Onlay - cast predominantly base metal, three or more surfaces $707 $813 $495

D6614 Onlay - cast noble metal, two surfaces $587 $675 $411

D6615 Onlay - cast noble metal, three or more surfaces $707 $813 $495

D6624 Inlay - titanium $991 $1,140 $694

D6634 Onlay - titanium $707 $813 $495

D6710 Crown - indirect resin based composite $991 $1,140 $694

D6720 Crown - resin with high noble metal $991 $1,140 $694

D6721 Crown - resin with predominantly base metal $991 $1,140 $694

D6722 Crown - resin with noble metal $991 $1,140 $694

D6740 Crown - porcelain/ceramic $1,078 $1,240 $755

D6750 Crown - porcelain fused to high noble metal $1,066 $1,226 $746

D6751 Crown - porcelain fused to predominantly base metal $991 $1,140 $694

D6752 Crown - porcelain fused to noble metal $1,023 $1,179 $716

D6780 Crown - 3/4 cast high noble metal $996 $1,145 $697

D6781 Crown - 3/4 cast predominantly base metal $991 $1,140 $694

D6782 Crown - 3/4 cast noble metal $991 $1,140 $694

D6783 Crown - 3/4 porcelain/ceramic $996 $1,145 $697

D6790 Crown - full cast high noble metal $1,055 $1,213 $739

D6791 Crown - full cast predominantly base metal $991 $1,140 $694

D6792 Crown - full cast noble metal $996 $1,145 $697

D6794 Crown - titanium $1,041 $1,197 $729

D6930 Re-cement or re-bond fixed partial denture $125 $144 $88

D6980Fixed partial denture repair necessitated by restorative material

failure$189 $217 $132

D7111 Extraction, coronal remnants - deciduous tooth $106 $122 $74

D7140Extraction, erupted tooth or exposed root (elevation and/or

forceps removal)$138 $159 $97

D7210

Surgical removal of erupted tooth requiring removal of bone

and/or sectioning of tooth, and including elevation of

mucoperiosteal flap if indicated

$255 $293 $179

D7220 Removal of impacted tooth - soft tissue $270 $311 $189

D7230 Removal of impacted tooth - partially bony $350 $405 $245

D7240 Removal of impacted tooth - completely bony $400 $505 $280

D7241Removal of impact tooth - completely bony, with unusual surgical

complications$425 $601 $298

D7250 Surgical removal of residual tooth roots (cutting procedure) $210 $300 $147

D7251 Coronectomy – intentional partial tooth removal $355 $450 $249

D7260 Oroantral fistula closure $475 $546 $333

D7261 Primary closure of a sinus perforation $50 $60 $35

D7270Tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth$478 $573 $335

D7280 Surgical access of an unerupted tooth $400 $530 $280

D7282 Mobilization of erupted or malpositioned tooth to aid eruption $105 $121 $74

D7285 Incisional biopsy of oral tissue - hard (bone, tooth) $340 $408 $238

D7286 Incisional biopsy of oral tissue - soft $263 $312 $184

D7290 Surgical repositioning of teeth $416 $499 $291

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $148 $170 $104

D7310Alveoloplasty in conjunction with extractions - four or more teeth

or tooth spaces, per quadrant$170 $197 $119

D7311Alveoloplasty in conjunction with extractions - one to three teeth

or tooth spaces, per quadrant$163 $197 $114

Effective 1/1/2017 RBS Metro Dental 7

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ADA CODE

CDT 2017DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D7320Alveoloplasty not in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant$222 $255 $155

D7321Alveoloplasty not in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant$222 $255 $155

D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $540 $621 $378

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts,

muscle reattachment, revisions of soft tissue attachment and

management of hypertrophied and hyperplastic tissue)

$600 $720 $420

D7410 Excision of benign lesion up to 1.25 cm $226 $275 $158

D7411 Excision of benign lesion greater than 1.25 cm $300 $360 $210

D7412 Excision of benign lesion, complicated $350 $420 $245

D7450Removal of benign odontogenic cyst or tumor - lesion diameter up

to 1.25 cm$339 $500 $237

D7451Removal of benign odontogenic cyst or tumor - lesion diameter

greater than 1.25 cm$516 $800 $361

D7465 Destruction of lesion(s) by physical or chemical method, by report $79 $91 $55

D7471 Removal of lateral exostosis (maxilla or mandible) $335 $385 $235

D7472 Removal of torus palatinus $335 $385 $235

D7473 Removal of torus mandibularis $365 $600 $256

D7485 Surgical reduction of osseous tuberosity $335 $385 $235

D7510 Incision and drain of abscess - intraoral soft tissue $149 $200 $104

D7511Incision and drainage of abscess - intraoral soft tissue -

complicated (includes drainage of multiple fascial spaces)$485 $558 $340

D7530Removal of foreign body from mucosa, skin, or subcutaneous

alveolar tissue$157 $181 $110

D7540Removal of reaction producing foreign bodies, musculoskeletal

system$131 $157 $92

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $225 $270 $158

D7560Maxillary sinusotomy for removal of tooth fragment or foreign

body$438 $525 $307

D7880 Occlusal orthotic device, by report $490 $564 $343

D7881 Occlusal orthotic device adjustment $79 $91 $55

D7910 Suture of recent small wounds up to 5 cm $206 $237 $144

D7911 Complicated suture - up to 5 cm $292 $336 $204

D7912 Complicated suture - greater than 5 cm $350 $403 $245

D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or

maxilla – autogenous or nonautogenous, by report$1,265 $1,455 $886

D7953 Bone replacement graft for ridge preservation - per site $305 $400 $214

D7960Frenulectomy – also known as frenectomy or frenotomy - separate

procedure not incidental to another$400 $460 $280

D7963 Frenuloplasty $178 $266 $125

D7970 Excision of hyperplastic tissue - per arch $200 $285 $140

D7971 Excision of periocoronal gingiva $160 $184 $112

D7972 Surgical reduction of fibrous tuberosity $335 $385 $235

D9110 Palliative (emergent) treatment of dental pain - minor procedure $125 $125 $88

D9120 Fixed partial denture sectioning $155 $155 $109

D9223 Deep sedation/general anesthesia – each 15 minute increment $145 $174 $102

D9243Intravenous moderate (conscious) sedation/analgesia – each 15

minute increment$112 $112 $78

D9248 Non-intravenous conscious sedation $80 $80 $56

D9410 House/extended care facility call $67 $67 $47

D9420 Hospital or ambulatory surgical center call $72 $72 $50

D9430Office visit for observation (during regularly scheduled hours) - no

other services performed$36 $36 $25

D9440 Office visit - after regularly scheduled hours $101 $101 $71

D9940 Occlusal guard, by report $475 $475 $333

D9942 Repair and/or reline of occlusal guard $52 $52 $36

D9943 Occlusal guard adjustment $79 $91 $55

Effective 1/1/2017 RBS Metro Dental 8

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ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

D0120 Periodic oral evaluation - established patient $57 $57 $40

D0140 Limited oral evaluation - problem focused $69 $90 $48

D0145Oral evaluation for patient under three years of age and counseling

with primary caregiver$56 $56 $39

D0150 Comprehensive oral evaluation - new or established patient $80 $80 $56

D0160Detailed and extensive oral evaluation - problem focused, by

report$125 $125 $88

D0170Re-evaluation - limited, problem focused (established patient; not

post-operative visit)$66 $66 $46

D0180 Comprehensive periodontal evaluation - new or established patient $97 $168 $68

D0210 Intraoral - complete series (including bitewings) $123 $123 $86

D0220 Intraoral - periapical first radiographic image $26 $26 $18

D0230 Intraoral - periapical each additional radiographic image $20 $20 $14

D0240 Intraoral - occlusal radiographic image $28 $28 $20

D0250Extraoral – 2D projection radiographic image created using a

stationary radiation source, and detector$60 $60 $42

D0251 Extraoral - posterior dental radiographic image $26 $26 $18

D0270 Bitewing - single radiographic image $20 $20 $14

D0272 Bitewings - two radiographic images $41 $41 $29

D0273 Bitewings - three radiographic images $47 $47 $33

D0274 Bitewings - four radiographic images $60 $60 $42

D0277 Vertical bitewings - 7 to 8 radiographic images $89 $89 $62

D0290Posterior - anterior or lateral skull and facial bone survey

radiographic image$37 $37 $26

D0320 Temporomandibular joint arthrogram, including injection $40 $40 $28

D0330 Panoramic radiographic image $98 $98 $69

D03402D cephalometric radiographic image – acquisition, measurement

and analysis$60 $60 $42

D0460 Pulp vitality tests $39 $39 $27

D1110 Prophylaxis – adult $111 $111 $78

D1120 Prophylaxis - child $72 $72 $50

D1206 Topical fluoride varnish $37 $37 $26

D1208 Topical application of fluoride – excluding varnish $37 $37 $26

D1330 Oral hygiene instructions $56 $56 $39

D1351 Sealant - per tooth $48 $48 $34

D1352Preventive resin restoration in a moderate to high caries risk

patient - permanent tooth$72 $72 $50

D1510 Space maintainer - fixed - unilateral $300 $300 $210

D1515 Space maintainer - fixed - bilateral $402 $402 $281

D1520 Space maintainer - removable – unilateral $280 $280 $196

D1525 Space maintainer - removable - bilateral $395 $395 $277

D1550 Re-cement or re-bond space maintainer $53 $53 $37

D1555 Removal of fixed space maintainer $35 $35 $25

D2140 Amalgam - one surface, primary or permanent $125 $125 $88

D2150 Amalgam - two surfaces, primary or permanent $181 $181 $127

PAR ALLOWED AMOUNTS

Confidential and Proprietary - Regence BlueShieldParticipating Dental Reimbursement Rates

Effective July 1, 2016

All published Regence BlueShield Administrative Guidelines apply.Payment shall be per the terms of your Provider Agreement and the Member’s benefit plan.

All services performed must be within the scope of the provider’s license. The absence of a code from this list does not necessarily mean the service is not paid to the fee schedule. Please notify Regence BlueShield if you have questions

concerning any code that may or may not be included on this list. The inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack thereof.

Effective 7/1/2016 RBS Metro Dental 1

Click the Bookmarks Tab to see fee schedules for previous effective dates

NON-PAR

ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2160 Amalgam - three surfaces, primary or permanent $217 $217 $152

D2161 Amalgam - four or more surfaces, primary or permanent $248 $248 $174

D2330 Resin-based composite - one surface, anterior $155 $155 $109

D2331 Resin- based composite - two surfaces, anterior $198 $198 $139

D2332 Resin-based composite - three surfaces, anterior $243 $243 $170

D2335Resin-based composite - four or more surfaces involving incisal

angle (anterior)$282 $282 $197

D2390 Resin-based composite crown - anterior $282 $282 $197

D2391 Resin-based composite - one surface, posterior $171 $171 $120

D2392 Resin-based composite - two surfaces, posterior $230 $230 $161

D2393 Resin-based composite - three surfaces, posterior $282 $282 $197

D2394 Resin-based composite - four or more surfaces, posterior $315 $315 $221

D2510 Inlay - metallic - one surface $574 $574 $402

D2520 Inlay - metallic - two surfaces $650 $650 $455

D2530 Inlay - metallic - three or more surfaces $873 $873 $611

D2542 Onlay - metallic - two surfaces $626 $626 $438

D2543 Onlay - metallic - three surfaces $908 $908 $636

D2544 Onlay - metallic - four or more surfaces $991 $991 $694

D2610 Inlay - porcelain/ceramic - one surface $574 $574 $402

D2620 Inlay - porcelain/ceramic - two surfaces $657 $657 $460

D2630 Inlay - porcelain/ceramic - three or more surfaces $800 $800 $560

D2642 Onlay - porcelain/ceramic - two surfaces $676 $676 $473

D2643 Onlay - porcelain/ceramic - three surfaces $963 $963 $674

D2644 Onlay - porcelain/ceramic - four or more surfaces $1,055 $1,055 $739

D2650 Inlay - resin-based composite - one surface $550 $550 $385

D2651 Inlay - resin based composite - two surfaces $600 $600 $420

D2652 Inlay- resin based composite - three or more surfaces $650 $650 $455

D2662 Onlay - resin based composite - two surfaces $626 $626 $438

D2663 Onlay - resin based composite - three surfaces $735 $735 $515

D2664 Onlay - resin based composite - four or more surfaces $808 $808 $566

D2710 Crown - resin-based composite (indirect) $330 $330 $231

D2712 Crown - 3/4 resin-based composite (indirect) $991 $991 $694

D2720 Crown - resin with high noble metal $996 $996 $697

D2721 Crown - resin with predominantly base metal $991 $991 $694

D2722 Crown - resin with noble metal $991 $991 $694

D2740 Crown - porcelain/ceramic substrate $1,078 $1,078 $755

D2750 Crown - porcelain fused to high noble metal $1,066 $1,066 $746

D2751 Crown - porcelain fused to predominantly base metal $991 $991 $694

D2752 Crown - porcelain fused to noble metal $1,023 $1,023 $716

D2780 Crown - 3/4 cast high noble metal $996 $996 $697

D2781 Crown - 3/4 cast predominately base metal $991 $991 $694

D2782 Crown - 3/4 cast noble metal $991 $991 $694

D2783 Crown - 3/4 porcelain/ceramic $996 $996 $697

D2790 Crown - full cast high noble metal $1,055 $1,055 $739

D2791 Crown - full cast predominantly base metal $991 $991 $694

D2792 Crown - full cast noble metal $996 $996 $697

D2794 Crown - titanium $1,041 $1,041 $729

D2910Re-cement or re-bond inlay, onlay, veneer or partial coverage

restoration$78 $78 $55

D2915Re-cement or re-bond indirectly fabricated or prefabricated post

and core$75 $75 $53

D2920 Re-cement or re-bond crown $83 $83 $58

D2921 Reattachment of tooth fragment, incisal edge or cusp $279 $279 $195

D2930 Prefabricated stainless steel crown - primary tooth $227 $227 $159

D2931 Prefabricated stainless steel crown - permanent tooth $230 $230 $161

D2932 Prefabricated resin crown $216 $216 $151

D2933 Prefab stainless steel crown with resin window $230 $230 $161

D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $230 $230 $161

D2940 Protective Restoration $83 $83 $58

D2941 Interim therapeutic restoration – primary dentition $80 $80 $56

D2949 Restorative foundation for an indirect restoration $205 $205 $144

D2950 Core buildup, including any pins when required $215 $215 $151

D2952 Post and core in addition to crown, indirectly fabricated $337 $337 $236

D2954 Prefabricated post and core in addition to crown $273 $273 $191

Effective 7/1/2016 RBS Metro Dental 2

NON-PAR

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CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D2955 Post removal $250 $250 $175

D2957 Each additional prefabricated post - same tooth $112 $112 $78

D2960 Labial veneer (resin laminate) – chairside $716 $716 $501

D2961 Labial veneer (resin laminate) – laboratory $812 $812 $568

D2962 Labial veneer (porcelain laminate) – laboratory $882 $882 $617

D2971Additional procedures to construct new crown under existing

partial denture framework$100 $100 $70

D2975 Coping $250 $250 $175

D2980 Crown repair necessitated by restorative material failure $150 $150 $105

D2990 Resin infiltration of incipient smooth surface lesions $60 $60 $42

D3110 Pulp cap - direct (excluding final restoration) $63 $72 $44

D3220

Therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application of

medicament

$144 $166 $101

D3221 Pulpal debridement, primary and permanent teeth $148 $170 $104

D3222Partial pulpotomy for apexogenesis - permanent tooth with

incomplete root development$125 $144 $88

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth $166 $191 $116

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth $226 $260 $158

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $650 $920 $455

D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $775 $1,071 $543

D3330 Endodontic therapy, molar (excluding final restoration) $935 $1,340 $655

D3331 Treatment of root canal obstruction; non-surgical access $112 $129 $78

D3332Incomplete endodontic therapy; inoperable, unrestorable or

fractured tooth$281 $323 $197

D3333 Internal root repair of perforation defects $350 $403 $245

D3346 Retreatment of previous root canal therapy - anterior $702 $950 $491

D3347 Retreatment of previous root canal therapy - bicuspid $820 $1,150 $574

D3348 Retreatment of previous root canal therapy - molar $1,055 $1,400 $739

D3351Apexification/recalcification - initial visit (apical closure/calcific

repair of perforations, root resorption, etc.)$175 $250 $123

D3352 Apexification/recalcification - interim mediation replacement $50 $58 $35

D3353

Apexification/recalcification - final visit (includes completed root

canal therapy - apical closure/calcific repair of perforations, root

resorption, etc.)

$215 $262 $151

D3355 Pulpal regeneration – initial visit $175 $250 $123

D3356 Pulpal regeneration – interim medication replacement $50 $58 $35

D3357 Pulpal regeneration – completion of treatment $215 $262 $151

D3410 Apicoectomy - anterior $547 $950 $383

D3421 Apicoectomy - bicuspid (first root) $547 $950 $383

D3425 Apicoectomy - molar (first root) $547 $950 $383

D3426 Apicoectomy (each additional root) $204 $305 $143

D3427 Periradicular surgery without apicoectomy $187 $325 $131

D3428Bone graft in conjunction with periradicular surgery – per tooth,

single site$367 $422 $257

D3429Bone graft in conjunction with periradicular surgery – each

additional contiguous tooth in the same surgical site$242 $278 $169

D3430 Retrograde filling - per root $153 $203 $107

D3431Biologic materials to aid in soft and osseous tissue regeneration in

conjunction with periradicular surgery$206 $310 $144

D3432Guided tissue regeneration, resorbable barrier, per site, in

conjunction with periradicular surgery$213 $245 $149

D3450 Root amputation - per root $242 $278 $169

D3470 Intentional reimplantation (including necessary splinting) $490 $564 $343

D3920Hemisection (including any root removal), not including root canal

therapy$383 $440 $268

D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant$383 $567 $268

Effective 7/1/2016 RBS Metro Dental 3

NON-PAR

ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or

tooth bounded spaces per quadrant$175 $201 $123

D4240Gingival flap procedure, including root planning - four or more

contiguous teeth or tooth bounded spaces per quadrant$625 $719 $438

D4241Gingival flap procedure, including root planning - one to three

contiguous teeth or tooth bounded spaces per quadrant$350 $403 $245

D4245 Apically positioned flap $477 $645 $334

D4249 Clinical crown lengthening - hard tissue $620 $875 $434

D4260

Osseous surgery (including elevation of full thickness flap and

closure) - four or more contiguous teeth or tooth bounded spaces

per quadrant

$1,000 $1,400 $700

D4261

Osseous surgery (including elevation of full thickness flap and

closure) - one to three contiguous teeth or tooth bounded spaces

per quadrant

$700 $1,150 $490

D4263 Bone replacement graft - first site in quadrant $367 $422 $257

D4264 Bone replacement graft - each additional site in quadrant $242 $278 $169

D4265 Biologic materials to aid in soft and osseous tissue regeneration $206 $310 $144

D4266 Guided tissue regeneration - resorbable barrier, per site $315 $446 $221

D4267Guided tissue regeneration - nonresorbable barrier, per site

(includes membrane removal)$213 $280 $149

D4268 Surgical revision procedure, per tooth $205 $246 $144

D4270 Pedicle soft tissue graft procedure $637 $823 $446

D4273

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) first tooth, implant, or edentulous tooth

position in graft

$800 $920 $560

D4274Distal or proximal wedge procedure (when not performed in

conjunction with surgical procedures in the same anatomical area)$382 $439 $267

D4275

Non-autogenous connective tissue graft (including recipient site

and donor material) first tooth, implant, or edentulous tooth

position in graft

$630 $1,005 $441

D4276 Combined connective tissue and double pedicle graft, per tooth $445 $735 $312

D4277

Free soft tissue graft procedure (including recipient and donor

surgical sites) first tooth, implant or edentulous tooth position in

graft

$800 $995 $560

D4278

Free soft tissue graft procedure (including recipient and donor

surgical sites) each additional contiguous tooth, implant or

edentulous tooth position in same graft site

$394 $515 $276

D4283

Autogenous connective tissue graft procedure (including donor and

recipient surgical sites) – each additional contiguous tooth, implant

or edentulous tooth position in same graft site

$600 $690 $420

D4285

Non-autogenous connective tissue graft procedure (including

recipient surgical site and donor material) – each additional

contiguous tooth, implant or edentulous tooth position in same

graft site

$473 $754 $331

D4341Periodontal scaling and root planning - four or more teeth per

quadrant $205 $282 $144

D4342Periodontal scaling and root planning - one to three teeth per

quadrant$130 $150 $91

D4355Full mouth debridement to enable comprehensive evaluation and

diagnosis$127 $146 $89

D4910 Periodontal maintenance $160 $184 $112

D4920Unscheduled dressing change (by someone other than treating

dentist)$32 $37 $22

D5110 Complete denture - maxillary $1,275 $1,469 $893

D5120 Complete denture - mandibular $1,275 $1,469 $893

D5130 Immediate denture - maxillary $1,275 $1,469 $893

D5140 Immediate denture - mandibular $1,275 $1,469 $893

D5211Maxillary partial denture - resin base (including any conventional

clasps, rests and teeth)$1,354 $1,557 $948

Effective 7/1/2016 RBS Metro Dental 4

NON-PAR

ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D5212Mandibular partial denture - resin base (including any conventional

clasps, rests and teeth)$1,354 $1,557 $948

D5213Maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)$1,360 $1,564 $952

D5214Mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)$1,360 $1,564 $952

D5221Immediate maxillary partial denture – resin base (including any

conventional clasps, rests and teeth)$1,354 $1,557 $948

D5222Immediate mandibular partial denture – resin base (including any

conventional clasps, rests and teeth)$1,354 $1,557 $948

D5223

Immediate maxillary partial denture – cast metal framework with

resin denture bases (including any conventional clasps, rests and

teeth)

$1,360 $1,564 $952

D5224

Immediate mandibular partial denture – cast metal framework

with resin denture bases (including any conventional clasps, rests

and teeth)

$1,360 $1,564 $952

D5225Maxillary partial denture - flexible base (including any clasps, rests

and teeth)$1,354 $1,557 $948

D5226Mandibular partial denture - flexible base (including any clasps,

rests and teeth)$1,354 $1,557 $948

D5281Removable unilateral partial denture - one piece cast metal

(including clasps and teeth)$850 $978 $595

D5410 Adjust complete denture - maxillary $79 $91 $55

D5411 Adjust complete denture - mandibular $79 $91 $55

D5421 Adjust partial denture - maxillary $65 $75 $46

D5422 Adjust partial denture - mandibular $65 $75 $46

D5510 Repair broken complete denture base $115 $132 $81

D5520 Replace missing or broken teeth - complete denture (each tooth) $115 $132 $81

D5610 Repair resin denture base $119 $137 $83

D5620 Repair cast framework $183 $210 $128

D5630 Repair or replace broken clasp - per tooth $134 $154 $94

D5640 Replace broken teeth - per tooth $113 $130 $79

D5650 Add tooth to existing partial denture $160 $184 $112

D5660 Add clasp to existing partial denture - per tooth $162 $186 $113

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $707 $813 $495

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $707 $813 $495

D5710 Rebase complete maxillary denture $468 $538 $328

D5711 Rebase complete mandibular denture $468 $538 $328

D5720 Rebase maxillary partial denture $468 $538 $328

D5721 Rebase mandibular partial denture $468 $538 $328

D5730 Reline complete maxillary denture (chairside) $256 $294 $179

D5731 Reline complete mandibular denture (chairside) $256 $294 $179

D5740 Reline maxillary partial denture (chairside) $224 $258 $157

D5741 Reline mandibular partial denture (chairside) $224 $258 $157

D5750 Reline complete maxillary denture (laboratory) $386 $444 $270

D5751 Reline complete mandibular denture (laboratory) $386 $444 $270

D5760 Reline maxillary partial denture (laboratory) $364 $419 $255

D5761 Reline mandibular partial denture (laboratory) $364 $419 $255

D5850 Tissue conditioning, maxillary $90 $104 $63

D5851 Tissue conditioning, mandibular $90 $104 $63

D5863 Overdenture – complete maxillary $1,257 $1,469 $880

D5864 Overdenture – partial maxillary $1,354 $1,557 $948

D5865 Overdenture – complete mandibular $1,257 $1,469 $880

D5866 Overdenture – partial mandibular $1,354 $1,557 $948

D6010 Surgical placement of implant body: endosteal implant $2,042 $2,348 $1,429

D6055 Connecting bar – implant supported or abutment supported $627 $721 $439

D6056 Prefabricated abutment – includes modification and placement $420 $483 $294

D6057 Custom fabricated abutment - includes placement $670 $771 $469

Effective 7/1/2016 RBS Metro Dental 5

NON-PAR

ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6058 Abutment supported porcelain/ceramic crown $1,078 $1,241 $755

D6059Abutment supported porcelain fused to metal crown (high noble

metal)$1,066 $1,226 $746

D6060Abutment supported porcelain fused to metal crown

(predominantly base metal)$991 $1,140 $694

D6061 Abutment supported porcelain fused to metal crown (noble metal) $1,023 $1,179 $716

D6062 Abutment supported cast metal crown (high noble metal) $1,055 $1,213 $739

D6063 Abutment supported cast metal crown (predominantly base metal) $991 $1,140 $694

D6064 Abutment supported cast metal crown (noble metal) $996 $1,145 $697

D6065 Implant supported porcelain/ceramic crown $1,078 $1,240 $755

D6066Implant supported porcelain fused to metal crown (titanium,

titanium allow, high noble metal)$1,066 $1,226 $746

D6067Implant supported metal crown (titanium, titanium alloy, high

noble metal)$1,055 $1,213 $739

D6068 Abutment supported retainer for porcelain/ceramic FPD $1,078 $1,240 $755

D6069Abutment supported retainer for porcelain fused to metal FPD

(high noble metal)$1,066 $1,226 $746

D6070Abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)$991 $1,140 $694

D6071Abutment supported retainer for porcelain fused to metal FPD

(noble metal)$1,025 $1,179 $718

D6072 Abutment supported retainer for cast metal FPD (high noble metal) $1,055 $1,213 $739

D6073Abutment supported retainer for cast metal FPD (predominantly

base metal)$991 $1,140 $694

D6074 Abutment supported retainer for cast metal FPD (noble metal) $996 $1,145 $697

D6075 Implant supported retainer for ceramic FPD $1,078 $1,240 $755

D6076Implant supported retainer porcelain fused to metal FPD (titanium,

titanium alloy, or high noble metal)$1,066 $1,226 $746

D6090 Repair implant supported prosthesis, by report $425 $489 $298

D6092 Re-cement or re-bond implant/abutment supported crown $76 $87 $53

D6093Re-cement or re-bond implant/abutment supported fixed partial

denture$106 $122 $74

D6094 Abutment supported crown (titanium) $991 $1,140 $694

D6095 Repair implant abutment, by report $250 $288 $175

D6100 Implant removal, by report $210 $242 $147

D6110Implant/abutment supported removable denture for edentulous

arch - maxillary$1,275 $1,469 $893

D6111Implant/abutment supported removable denture for edentulous

arch – mandibular$1,275 $1,469 $893

D6112Implant/abutment supported removable denture for partially

edentulous arch – maxillary$1,354 $1,557 $948

D6113Implant /abutment supported removable denture for partially

edentulous arch - mandibular$1,354 $1,557 $948

D6194 Abutment supported retainer crown for cast metal FPD (titanium) $1,041 $1,197 $729

D6205 Pontic - indirect resin based composite $400 $460 $280

D6210 Pontic - cast high noble metal $942 $1,083 $659

D6211 Pontic - cast predominantly base metal $942 $1,083 $659

D6212 Pontic - cast noble metal $942 $1,083 $659

D6214 Pontic - titanium $942 $1,083 $659

D6240 Pontic - porcelain fused to high noble metal $950 $1,093 $665

D6241 Pontic - porcelain fused to predominantly base metal $942 $1,083 $659

D6242 Pontic - porcelain fused to noble metal $950 $1,093 $665

D6245 Pontic - porcelain/ceramic $950 $1,093 $665

D6250 Pontic - resin with high noble metal $942 $1,083 $659

D6251 Pontic - resin with predominantly base metal $942 $1,083 $659

D6252 Pontic - resin with noble metal $942 $1,083 $659

D6545 Retainer- cast metal for resin bonded fixed prosthesis $500 $575 $350

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $500 $976 $350

Effective 7/1/2016 RBS Metro Dental 6

NON-PAR

ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D6549 Resin retainer-for resin bonded fixed prosthesis $849 $976 $594

D6608 Onlay - porcelain/ceramic, two surfaces $626 $720 $438

D6609 Onlay - porcelain/ceramic, three or more surfaces $1,028 $1,182 $720

D6610 Onlay - cast high noble metal, two surfaces $587 $675 $411

D6611 Onlay - cast high noble metal, three or more surfaces $707 $813 $495

D6612 Onlay - cast predominantly base metal, two surfaces $587 $675 $411

D6613 Onlay - cast predominantly base metal, three or more surfaces $707 $813 $495

D6614 Onlay - cast noble metal, two surfaces $587 $675 $411

D6615 Onlay - cast noble metal, three or more surfaces $707 $813 $495

D6624 Inlay - titanium $991 $1,140 $694

D6634 Onlay - titanium $707 $813 $495

D6710 Crown - indirect resin based composite $991 $1,140 $694

D6720 Crown - resin with high noble metal $991 $1,140 $694

D6721 Crown - resin with predominantly base metal $991 $1,140 $694

D6722 Crown - resin with noble metal $991 $1,140 $694

D6740 Crown - porcelain/ceramic $1,078 $1,240 $755

D6750 Crown - porcelain fused to high noble metal $1,066 $1,226 $746

D6751 Crown - porcelain fused to predominantly base metal $991 $1,140 $694

D6752 Crown - porcelain fused to noble metal $1,023 $1,179 $716

D6780 Crown - 3/4 cast high noble metal $996 $1,145 $697

D6781 Crown - 3/4 cast predominantly base metal $991 $1,140 $694

D6782 Crown - 3/4 cast noble metal $991 $1,140 $694

D6783 Crown - 3/4 porcelain/ceramic $996 $1,145 $697

D6790 Crown - full cast high noble metal $1,055 $1,213 $739

D6791 Crown - full cast predominantly base metal $991 $1,140 $694

D6792 Crown - full cast noble metal $996 $1,145 $697

D6794 Crown - titanium $1,041 $1,197 $729

D6930 Re-cement or re-bond fixed partial denture $125 $144 $88

D6980Fixed partial denture repair necessitated by restorative material

failure$189 $217 $132

D7111 Extraction, coronal remnants - deciduous tooth $106 $122 $74

D7140Extraction, erupted tooth or exposed root (elevation and/or

forceps removal)$138 $159 $97

D7210

Surgical removal of erupted tooth requiring removal of bone

and/or sectioning of tooth, and including elevation of

mucoperiosteal flap if indicated

$255 $293 $179

D7220 Removal of impacted tooth - soft tissue $270 $311 $189

D7230 Removal of impacted tooth - partially bony $350 $405 $245

D7240 Removal of impacted tooth - completely bony $400 $505 $280

D7241Removal of impact tooth - completely bony, with unusual surgical

complications$425 $601 $298

D7250 Surgical removal of residual tooth roots (cutting procedure) $210 $300 $147

D7251 Coronectomy – intentional partial tooth removal $355 $450 $249

D7260 Oroantral fistula closure $475 $546 $333

D7261 Primary closure of a sinus perforation $50 $60 $35

D7270Tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth$478 $573 $335

D7280 Surgical access of an unerupted tooth $400 $530 $280

D7282 Mobilization of erupted or malpositioned tooth to aid eruption $105 $121 $74

D7285 Incisional biopsy of oral tissue - hard (bone, tooth) $340 $408 $238

D7286 Incisional biopsy of oral tissue - soft $263 $312 $184

D7290 Surgical repositioning of teeth $416 $499 $291

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $148 $170 $104

D7310Alveoloplasty in conjunction with extractions - four or more teeth

or tooth spaces, per quadrant$170 $197 $119

D7311Alveoloplasty in conjunction with extractions - one to three teeth

or tooth spaces, per quadrant$163 $197 $114

D7320Alveoloplasty not in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant$222 $255 $155

D7321Alveoloplasty not in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant$222 $255 $155

Effective 7/1/2016 RBS Metro Dental 7

NON-PAR

ADA CODE

CDT 2016 DESCRIPTION

GENERAL

PRACTICESPECIALIST

GENERAL

PRACTICE &

SPECIALIST

PAR ALLOWED AMOUNTS

D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $540 $621 $378

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts,

muscle reattachment, revisions of soft tissue attachment and

management of hypertrophied and hyperplastic tissue)

$600 $720 $420

D7410 Excision of benign lesion up to 1.25 cm $226 $275 $158

D7411 Excision of benign lesion greater than 1.25 cm $300 $360 $210

D7412 Excision of benign lesion, complicated $350 $420 $245

D7450Removal of benign odontogenic cyst or tumor - lesion diameter up

to 1.25 cm$339 $500 $237

D7451Removal of benign odontogenic cyst or tumor - lesion diameter

greater than 1.25 cm$516 $800 $361

D7465 Destruction of lesion(s) by physical or chemical method, by report $79 $91 $55

D7471 Removal of lateral exostosis (maxilla or mandible) $335 $385 $235

D7472 Removal of torus palatinus $335 $385 $235

D7473 Removal of torus mandibularis $365 $600 $256

D7485 Surgical reduction of osseous tuberosity $335 $385 $235

D7510 Incision and drain of abscess - intraoral soft tissue $149 $200 $104

D7511Incision and drainage of abscess - intraoral soft tissue -

complicated (includes drainage of multiple fascial spaces)$485 $558 $340

D7530Removal of foreign body from mucosa, skin, or subcutaneous

alveolar tissue$157 $181 $110

D7540Removal of reaction producing foreign bodies, musculoskeletal

system$131 $157 $92

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $225 $270 $158

D7560Maxillary sinusotomy for removal of tooth fragment or foreign

body$438 $525 $307

D7880 Occlusal orthotic device, by report $490 $564 $343

D7881 Occlusal orthotic device adjustment $79 $91 $55

D7910 Suture of recent small wounds up to 5 cm $206 $237 $144

D7911 Complicated suture - up to 5 cm $292 $336 $204

D7912 Complicated suture - greater than 5 cm $350 $403 $245

D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or

maxilla – autogenous or nonautogenous, by report$1,265 $1,455 $886

D7953 Bone replacement graft for ridge preservation - per site $305 $400 $214

D7960Frenulectomy – also known as frenectomy or frenotomy - separate

procedure not incidental to another$400 $460 $280

D7963 Frenuloplasty $178 $266 $125

D7970 Excision of hyperplastic tissue - per arch $200 $285 $140

D7971 Excision of periocoronal gingiva $160 $184 $112

D7972 Surgical reduction of fibrous tuberosity $335 $385 $235

D9110 Palliative (emergent) treatment of dental pain - minor procedure $125 $125 $88

D9120 Fixed partial denture sectioning $155 $155 $109

D9223 Deep sedation/general anesthesia – each 15 minute increment $145 $174 $102

D9243Intravenous moderate (conscious) sedation/analgesia – each 15

minute increment$112 $112 $78

D9248 Non-intravenous conscious sedation $80 $80 $56

D9410 House/extended care facility call $67 $67 $47

D9420 Hospital or ambulatory surgical center call $72 $72 $50

D9430Office visit for observation (during regularly scheduled hours) - no

other services performed$36 $36 $25

D9440 Office visit - after regularly scheduled hours $101 $101 $71

D9940 Occlusal guard, by report $475 $475 $333

D9942 Repair and/or reline of occlusal guard $52 $52 $36

D9943 Occlusal guard adjustment $79 $91 $55

Effective 7/1/2016 RBS Metro Dental 8