Confidential and Proprietary - Regence BlueCross ... Periradicular surgery without apicoectomy $591 ... Gingivectomy or ... bounded spaces per quadrant $196 D4240 Gingival flap procedure,

ADA CODE

CDT 2018DESCRIPTION ALLOWABLE

D0120 Periodic oral evaluation - established patient $56

D0140 Limited oral evaluation - problem focused $71

D0145Oral evaluation for patient under three years of age and counseling with

primary caregiver$65

D0150 Comprehensive oral evaluation - new or established patient $81

D0160 Detailed and extensive oral evaluation - problem focused, by report $115

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

operative visit)$65

D0180 Comprehensive periodontal evaluation - new or established patient $110

D0210 Intraoral - complete series (including bitewings) $110

D0220 Intraoral - periapical first radiographic image $25

D0230 Intraoral - periapical each additional radiographic image $20

D0240 Intraoral - occlusal radiographic image $39

D0250Extraoral – 2D projection radiographic image created using a stationary

radiation source, and detector$101

D0251 Extraoral - posterior dental radiographic image $43

D0270 Bitewing - single radiographic image $25

D0272 Bitewings - two radiographic images $42

D0273 Bitewings - three radiographic images $52

D0274 Bitewings - four radiographic images $62

D0277 Vertical bitewings - 7 to 8 radiographic images $88

D0320 Temporomandibular joint arthrogram, including injection $40

D0330 Panoramic radiographic image $100

Confidential and Proprietary - Regence BlueCross BlueShield of Oregon

Participating Dental Reimbursement Rates

Effective January 1, 2018

All published Regence BlueCross 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 BlueCross

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 Oregon Dental 1

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

ADA CODE


D03402D cephalometric radiographic image – acquisition, measurement and

analysis$101

D0460 Pulp vitality tests $51

D1110 Prophylaxis – adult $90

D1120 Prophylaxis - child $68

D1206 Topical fluoride varnish $37

D1208 Topical application of fluoride – excluding varnish $39

D1330 Oral hygiene instructions $58

D1351 Sealant - per tooth $50

D1352Preventive resin restoration in a moderate to high caries risk patient -

permanent tooth$76

D1510 Space maintainer - fixed - unilateral $300

D1515 Space maintainer - fixed - bilateral $419

D1520 Space maintainer - removable – unilateral $404

D1525 Space maintainer - removable - bilateral $278

D1550 Re-cement or re-bond space maintainer $65

D1575 Distal shoe space maintainer -- fixed / unilateral $288

D1555 Removal of fixed space maintainer $77

D2140 Amalgam - one surface, primary or permanent $146

D2150 Amalgam - two surfaces, primary or permanent $181

D2160 Amalgam - three surfaces, primary or permanent $227

D2161 Amalgam - four or more surfaces, primary or permanent $258

D2330 Resin-based composite - one surface, anterior $142

D2331 Resin- based composite - two surfaces, anterior $180

D2332 Resin-based composite - three surfaces, anterior $209

D2335Resin-based composite - four or more surfaces involving incisal angle

(anterior)$255

D2390 Resin-based composite crown - anterior $325

D2391 Resin-based composite - one surface, posterior $155

D2392 Resin-based composite - two surfaces, posterior $201

D2393 Resin-based composite - three surfaces, posterior $237

D2394 Resin-based composite - four or more surfaces, posterior $273

D2510 Inlay - metallic - one surface $606

D2520 Inlay - metallic - two surfaces $707

D2530 Inlay - metallic - three or more surfaces $808

D2542 Onlay - metallic - two surfaces $783

D2543 Onlay - metallic - three surfaces $859

D2544 Onlay - metallic - four or more surfaces $884

D2610 Inlay - porcelain/ceramic - one surface $631

D2620 Inlay - porcelain/ceramic - two surfaces $682

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

D2642 Onlay - porcelain/ceramic - two surfaces $783

D2643 Onlay - porcelain/ceramic - three surfaces $862

D2644 Onlay - porcelain/ceramic - four or more surfaces $884

D2650 Inlay - resin-based composite - one surface $429


ADA CODE


D2651 Inlay - resin based composite - two surfaces $480

D2652 Inlay- resin based composite - three or more surfaces $530

D2662 Onlay - resin based composite - two surfaces $707

D2663 Onlay - resin based composite - three surfaces $763

D2664 Onlay - resin based composite - four or more surfaces $783

D2710 Crown - resin-based composite (indirect) $253

D2712 Crown - 3/4 resin-based composite (indirect) $732

D2720 Crown - resin with high noble metal $783

D2721 Crown - resin with predominantly base metal $601

D2722 Crown - resin with noble metal $636

D2740 Crown - porcelain/ceramic $1,010

D2750 Crown - porcelain fused to high noble metal $1,010

D2751 Crown - porcelain fused to predominantly base metal $909

D2752 Crown - porcelain fused to noble metal $960

D2780 Crown - 3/4 cast high noble metal $940

D2781 Crown - 3/4 cast predominately base metal $813

D2782 Crown - 3/4 cast noble metal $988

D2783 Crown - 3/4 porcelain/ceramic $884

D2790 Crown - full cast high noble metal $1,010

D2791 Crown - full cast predominantly base metal $899

D2792 Crown - full cast noble metal $1,010

D2794 Crown - titanium $909

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $82

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core $121

D2920 Re-cement or re-bond crown $87

D2921 Reattachment of tooth fragment, incisal edge or cusp $237

D2930 Prefabricated stainless steel crown - primary tooth $275

D2931 Prefabricated stainless steel crown - permanent tooth $300

D2932 Prefabricated resin crown $268

D2933 Prefab stainless steel crown with resin window $340

D2934 Prefabricated esthetic coated stainless steel crown - primary tooth $330

D2940 Protective Restoration $95

D2941 Interim therapeutic restoration – primary dentition $80

D2949 Restorative foundation for an indirect restoration $197

D2950 Core buildup, including any pins when required $210

D2952 Post and core in addition to crown, indirectly fabricated $328

D2954 Prefabricated post and core in addition to crown $275

D2955 Post removal $253

D2957 Each additional prefabricated post - same tooth $101

D2960 Labial veneer (resin laminate) – chairside $645

D2961 Labial veneer (resin laminate) – laboratory $876

D2962 Labial veneer (porcelain laminate) – laboratory $859


ADA CODE


D2971Additional procedures to construct new crown under existing partial

denture framework$101

D2975 Coping $354

D2980 Crown repair necessitated by restorative material failure $178

D2990 Resin infiltration of incipient smooth surface lesions $97

D3110 Pulp cap - direct (excluding final restoration) $75

D3220Therapeutic pulpotomy (excluding final restoration) - removal of pulp

coronal to the dentinocemental junction and application of medicament$187

D3221 Pulpal debridement, primary and permanent teeth $184

D3222Partial pulpotomy for apexogenesis - permanent tooth with incomplete

root development$154

D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth $235

D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth $229

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

D3320 Endodontic therapy, premolar tooth (excluding final restoration) $750

D3330 Endodontic therapy, molar tooth (excluding final restoration) $975

D3331 Treatment of root canal obstruction; non-surgical access $227

D3332Incomplete endodontic therapy; inoperable, unrestorable or fractured

tooth$342

D3333 Internal root repair of perforation defects $253

D3346 Retreatment of previous root canal therapy - anterior $863

D3347 Retreatment of previous root canal therapy - premolar $990

D3348 Retreatment of previous root canal therapy - molar $1,195

D3351Apexification/recalcification - initial visit (apical closure/calcific repair of

perforations, root resorption, etc.)$354

D3352 Apexification/recalcification - interim mediation replacement $126

D3353Apexification/recalcification - final visit (includes completed root canal

therapy - apical closure/calcific repair of perforations, root resorption, etc.)$354

D3355 Pulpal regeneration – initial visit $354

D3356 Pulpal regeneration – interim medication replacement $126

D3357 Pulpal regeneration – completion of treatment $354

D3410 Apicoectomy - anterior $800

D3421 Apicoectomy - premolar (first root) $900

D3425 Apicoectomy - molar (first root) $944

D3426 Apicoectomy (each additional root) $294

D3427 Periradicular surgery without apicoectomy $591

D3428 Bone graft in conjunction with periradicular surgery – per tooth, single site $379

D3429Bone graft in conjunction with periradicular surgery – each additional

contiguous tooth in the same surgical site$328

D3430 Retrograde filling - per root $333

D3431Biologic materials to aid in soft and osseous tissue regeneration in

conjunction with periradicular surgery$376


ADA CODE


D3432Guided tissue regeneration, resorbable barrier, per site, in conjunction

with periradicular surgery$278

D3450 Root amputation - per root $735

D3470 Intentional reimplantation (including necessary splinting) $495

D3920 Hemisection (including any root removal), not including root canal therapy $379

D4210Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth

bounded spaces per quadrant$429

D4211Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth


D4240Gingival flap procedure, including root planning - four or more contiguous

teeth or tooth bounded spaces per quadrant$859

D4241Gingival flap procedure, including root planning - one to three contiguous


D4245 Apically positioned flap $455

D4249 Clinical crown lengthening - hard tissue $758

D4260Osseous surgery (including elevation of full thickness flap and closure) -

four or more contiguous teeth or tooth bounded spaces per quadrant$1,050

D4261Osseous surgery (including elevation of full thickness flap and closure) -

one to three contiguous teeth or tooth bounded spaces per quadrant$900

D4263 Bone replacement graft - first site in quadrant $444

D4264 Bone replacement graft - each additional site in quadrant $401

D4265 Biologic materials to aid in soft and osseous tissue regeneration $376

D4266 Guided tissue regeneration - resorbable barrier, per site $394

D4267Guided tissue regeneration - nonresorbable barrier, per site (includes

membrane removal)$340

D4268 Surgical revision procedure, per tooth $180

D4270 Pedicle soft tissue graft procedure $823

D4273

Autogenous connective tissue graft procedure (including donor and

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

graft

$1,000

D4274Distal or proximal wedge procedure (when not performed in conjunction

with surgical procedures in the same anatomical area)$505

D4275Non-autogenous connective tissue graft (including recipient site and donor

material) first tooth, implant, or edentulous tooth position in graft$900

D4276 Combined connective tissue and double pedicle graft, per tooth $758

D4277Free soft tissue graft procedure (including recipient and donor surgical

sites) first tooth, implant or edentulous tooth position in graft$925


ADA CODE


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

$429

D4283


recipient surgical sites) – each additional contiguous tooth, implant or

edentulous tooth position in same graft site

$690

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

$590

D4341 Periodontal scaling and root planning - four or more teeth per quadrant $250

D4342 Periodontal scaling and root planning - one to three teeth per quadrant $180

D4346Scaling in presence of generalized moderate or severe gingival inflamation -

- full mouth, after oral evaluation$139

D4355Full mouth debridement to enable comprehensive evaluation and

diagnosis on a subsequent visit$160

D4910 Periodontal maintenance $145

D4920 Unscheduled dressing change (by someone other than treating dentist) $32

D5110 Complete denture - maxillary $1,111

D5120 Complete denture - mandibular $1,111

D5130 Immediate denture - maxillary $1,260

D5140 Immediate denture - mandibular $1,260

D5211Maxillary partial denture - resin base (including any conventional clasps,

rests and teeth)$934

D5212Mandibular partial denture - resin base (including any conventional clasps,


D5213Maxillary partial denture - cast metal framework with resin denture bases

(including any conventional clasps, rests and teeth)$1,283

D5214Mandibular partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)$1,283

D5221Immediate maxillary partial denture – resin base (including any

conventional clasps, rests and teeth)$934

D5222Immediate mandibular partial denture – resin base (including any


D5223Immediate maxillary partial denture – cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)$1,283

D5224Immediate mandibular partial denture – cast metal framework with resin



ADA CODE


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

teeth)$1,063

D5226Mandibular partial denture - flexible base (including any clasps, rests and

teeth)$1,063

D5281Removable unilateral partial denture - one piece cast metal (including

clasps and teeth)$758

D5410 Adjust complete denture - maxillary $77

D5411 Adjust complete denture - mandibular $77

D5421 Adjust partial denture - maxillary $77

D5422 Adjust partial denture - mandibular $77

D5511 Repair broken complete denture base, mandibular $143

D5512 Repair broken complete denture base, maxillary $143

D5520 Replace missing or broken teeth - complete denture (each tooth) $131

D5611 Repair resin partial denture base, mandibular $141

D5612 Repair broken complete denture base, maxillary $141

D5621 Repair cast partial framework, mandibular $260

D5622 Repair cast partial framework, maxillary $260

D5630 Repair or replace broken clasp - per tooth $202

D5640 Replace broken teeth - per tooth $150

D5650 Add tooth to existing partial denture $175

D5660 Add clasp to existing partial denture - per tooth $238

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $687

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

D5710 Rebase complete maxillary denture $455

D5711 Rebase complete mandibular denture $455

D5720 Rebase maxillary partial denture $480

D5721 Rebase mandibular partial denture $480

D5730 Reline complete maxillary denture (chairside) $263

D5731 Reline complete mandibular denture (chairside) $263

D5740 Reline maxillary partial denture (chairside) $247

D5741 Reline mandibular partial denture (chairside) $247

D5750 Reline complete maxillary denture (laboratory) $354

D5751 Reline complete mandibular denture (laboratory) $354

D5760 Reline maxillary partial denture (laboratory) $354

D5761 Reline mandibular partial denture (laboratory) $354

D5850 Tissue conditioning, maxillary $101

D5851 Tissue conditioning, mandibular $101

D5863 Overdenture – complete maxillary $1,111

D5864 Overdenture – partial maxillary $1,111

D5865 Overdenture – complete mandibular $1,111

D5866 Overdenture – partial mandibular $1,111

D6010 Surgical placement of implant body: endosteal implant $2,100

D6055 Connecting bar – implant supported or abutment supported $616

D6056 Prefabricated abutment – includes modification and placement $524


ADA CODE


D6057 Custom fabricated abutment - includes placement $607

D6058 Abutment supported porcelain/ceramic crown $1,200

D6059 Abutment supported porcelain fused to metal crown (high noble metal) $1,200

D6060Abutment supported porcelain fused to metal crown (predominantly base

metal)$909

D6061 Abutment supported porcelain fused to metal crown (noble metal) $1,111

D6062 Abutment supported cast metal crown (high noble metal) $1,200

D6063 Abutment supported cast metal crown (predominantly base metal) $899

D6064 Abutment supported cast metal crown (noble metal) $1,100

D6065 Implant supported porcelain/ceramic crown $1,212

D6066Implant supported porcelain fused to metal crown (titanium, titanium

allow, high noble metal)$1,200

D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) $1,212

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

D6069Abutment supported retainer for porcelain fused to metal FPD (high noble

metal)$1,200

D6070Abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)$900

D6071Abutment supported retainer for porcelain fused to metal FPD (noble

metal)$1,100

D6072 Abutment supported retainer for cast metal FPD (high noble metal) $1,200

D6073Abutment supported retainer for cast metal FPD (predominantly base

metal)$899

D6074 Abutment supported retainer for cast metal FPD (noble metal) $1,100

D6075 Implant supported retainer for ceramic FPD $1,010

D6076Implant supported retainer porcelain fused to metal FPD (titanium,

titanium alloy, or high noble metal)$1,010

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

$172

D6085 Provisional implant crown $418

D6090 Repair implant supported prosthesis, by report $429

D6092 Re-cement or re-bond implant/abutment supported crown $125

D6093 Re-cement or re-bond implant/abutment supported fixed partial denture $111

D6094 Abutment supported crown (titanium) $909

D6095 Repair implant abutment, by report $253

D6096 Remove broken implant retaining screw $150

D6100 Implant removal, by report $300


ADA CODE


D6110Implant/abutment supported removable denture for edentulous arch -

maxillary$1,212

D6111Implant/abutment supported removable denture for edentulous arch –

mandibular$1,212

D6112Implant/abutment supported removable denture for partially edentulous

arch – maxillary$1,212

D6113Implant /abutment supported removable denture for partially edentulous

arch - mandibular$1,212

D6194 Abutment supported retainer crown for cast metal FPD (titanium) $909

D6205 Pontic - indirect resin based composite $717

D6210 Pontic - cast high noble metal $843

D6211 Pontic - cast predominantly base metal $758

D6212 Pontic - cast noble metal $823

D6214 Pontic - titanium $823

D6240 Pontic - porcelain fused to high noble metal $859

D6241 Pontic - porcelain fused to predominantly base metal $909

D6242 Pontic - porcelain fused to noble metal $859

D6245 Pontic - porcelain/ceramic $884

D6250 Pontic - resin with high noble metal $783

D6251 Pontic - resin with predominantly base metal $394

D6252 Pontic - resin with noble metal $717

D6545 Retainer- cast metal for resin bonded fixed prosthesis $442

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis $783

D6549 Resin retainer-for resin bonded fixed prosthesis $442

D6608 Onlay - porcelain/ceramic, two surfaces $758

D6609 Onlay - porcelain/ceramic, three or more surfaces $758

D6610 Onlay - cast high noble metal, two surfaces $707

D6611 Onlay - cast high noble metal, three or more surfaces $758

D6612 Onlay - cast predominantly base metal, two surfaces $707

D6613 Onlay - cast predominantly base metal, three or more surfaces $707

D6614 Onlay - cast noble metal, two surfaces $707

D6615 Onlay - cast noble metal, three or more surfaces $783

D6624 Inlay - titanium $636

D6634 Onlay - titanium $682

D6710 Crown - indirect resin based composite $601









D6781 Crown - 3/4 cast predominantly base metal $805



ADA CODE







D6930 Re-cement or re-bond fixed partial denture $135

D6980 Fixed partial denture repair necessitated by restorative material failure $242

D7111 Extraction, coronal remnants - primary tooth $125

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

removal)$150

D7210

Surgical removal of erupted tooth requiring removal of bone and/or

sectioning of tooth, and including elevation of mucoperiosteal flap if

indicated

$260

D7220 Removal of impacted tooth - soft tissue $320

D7230 Removal of impacted tooth - partially bony $395

D7240 Removal of impacted tooth - completely bony $450

D7241Removal of impact tooth - completely bony, with unusual surgical

complications$550

D7250 Surgical removal of residual tooth roots (cutting procedure) $280

D7251 Coronectomy – intentional partial tooth removal $392

D7260 Oroantral fistula closure $455

D7261 Primary closure of a sinus perforation $51

D7270Tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth$450

D7280 Surgical access of an unerupted tooth $495

D7282 Mobilization of erupted or malpositioned tooth to aid eruption $250

D7285 Incisional biopsy of oral tissue - hard (bone, tooth) $364

D7286 Incisional biopsy of oral tissue - soft $325

D7290 Surgical repositioning of teeth $290

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report $91

D7310Alveoloplasty in conjunction with extractions - four or more teeth or tooth

spaces, per quadrant$275

D7311Alveoloplasty in conjunction with extractions - one to three teeth or tooth


D7320Alveoloplasty not in conjunction with extractions - four or more teeth or

tooth spaces, per quadrant$294

D7321Alveoloplasty not in conjunction with extractions - one to three teeth or


D7340 Vestibuloplasty - ridge extension (secondary epithelialization) $657

D7350

Vestibuloplasty - ridge extension (including soft tissue grafts, muscle

reattachment, revisions of soft tissue attachment and management of

hypertrophied and hyperplastic tissue)

$682

D7410 Excision of benign lesion up to 1.25 cm $270

D7411 Excision of benign lesion greater than 1.25 cm $278


ADA CODE


D7412 Excision of benign lesion, complicated $275

D7450Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25

cm$505

D7451Removal of benign odontogenic cyst or tumor - lesion diameter greater

than 1.25 cm$707

D7465 Destruction of lesion(s) by physical or chemical method, by report $212

D7471 Removal of lateral exostosis (maxilla or mandible) $455

D7472 Removal of torus palatinus $455

D7473 Removal of torus mandibularis $606

D7485 Surgical reduction of osseous tuberosity $404

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

D7511Incision and drainage of abscess - intraoral soft tissue - complicated

(includes drainage of multiple fascial spaces)$202

D7530Removal of foreign body from mucosa, skin, or subcutaneous alveolar

tissue$159

D7540 Removal of reaction producing foreign bodies, musculoskeletal system $152

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone $354

D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body $227

D7880 Occlusal orthotic device, by report $480

D7881 Occlusal orthotic device adjustment $63

D7910 Suture of recent small wounds up to 5 cm $172

D7911 Complicated suture - up to 5 cm $245

D7912 Complicated suture - greater than 5 cm $308

D7950Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla –

autogenous or nonautogenous, by report$1,010

D7953 Bone replacement graft for ridge preservation - per site $375

D7960Frenulectomy – also known as frenectomy or frenotomy - separate

procedure not incidental to another$450

D7963 Frenuloplasty $428

D7970 Excision of hyperplastic tissue - per arch $126

D7971 Excision of periocoronal gingiva $200

D7972 Surgical reduction of fibrous tuberosity $455

D9110 Palliative (emergent) treatment of dental pain - minor procedure $133

D9120 Fixed partial denture sectioning $157

D9222 Deep sedation/general anesthesia - first 15 minutes $193

D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment $175

D9239 Intravenous moderate (conscious) sedation/analgesia- first 15 minutes $156

D9243Intravenous moderate (conscious) sedation/analgesia – each subsequent

15 minute increment$142

D9248 Non-intravenous conscious sedation $177

D9410 House/extended care facility call $140


ADA CODE


D9420 Hospital or ambulatory surgical center call $288

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

services performed$59

D9440 Office visit - after regularly scheduled hours $106

D9940 Occlusal guard, by report $415

D9942 Repair and/or reline of occlusal guard $91

D9943 Occlusal guard adjustment $63


ADA CODE









operative visit)$65

















analysis$101









permanent tooth$76















Confidential and Proprietary - Regence BlueCross BlueShield of OregonParticipating Dental Reimbursement Rates

Effective July 1, 2017

All published Regence BlueCross 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 BlueCross

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.



ADA CODE



(anterior)$255





























D2740 Crown - porcelain/ceramic substrate $1,010


































D2975 Coping $354


ADA CODE








D3222Partial pulpotomy for apexogenesis - permanent tooth with incomplete root

development$154




D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) $750

D3330 Endodontic therapy, molar (excluding final restoration) $975


D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $342



D3347 Retreatment of previous root canal therapy - bicuspid $990











D3421 Apicoectomy - bicuspid (first root) $900










D3432Guided tissue regeneration, resorbable barrier, per site, in conjunction with

periradicular surgery$278














D4260Osseous surgery (including elevation of full thickness flap and closure) - four

or more contiguous teeth or tooth bounded spaces per quadrant$1,050

D4261Osseous surgery (including elevation of full thickness flap and closure) - one

to three contiguous teeth or tooth bounded spaces per quadrant$900






ADA CODE






D4273



graft

$1,000






D4277Free soft tissue graft procedure (including recipient and donor surgical sites)

first tooth, implant or edentulous tooth position in graft$925

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

$429

D4283




$690

D4285




$590



D4346Scaling in presence of generalized moderate or severe gingival inflamation --

full mouth, after oral evaluation$139

D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $160













D5214Mandibular partial denture - cast metal framework with resin denture bases











teeth)$1,063


teeth)$1,063

D5281Removable unilateral partial denture - one piece cast metal (including clasps

and teeth)$758


ADA CODE






D5510 Repair broken complete denture base $143


D5610 Repair resin denture base $141

D5620 Repair cast framework $260
































metal)$909






D6066Implant supported porcelain fused to metal crown (titanium, titanium allow,

high noble metal)$1,200




metal)$1,200


(predominantly base metal)$900


metal)$1,100



metal)$899



D6076Implant supported retainer porcelain fused to metal FPD (titanium, titanium

alloy, or high noble metal)$1,010


ADA CODE


D6081


single implant, including cleaning of the implant surfaces, without flap entry

and closure

$172









maxillary$1,212


mandibular$1,212

















































D7111 Extraction, coronal remnants - deciduous tooth $125


removal)$150


ADA CODE


D7210



indicated

$260





complications$550






displaced tooth$450
















D7350




$682





cm$505

D7451Removal of benign odontogenic cyst or tumor - lesion diameter greater than

1.25 cm$707










tissue$159



















ADA CODE




D9223 Deep sedation/general anesthesia – each 15 minute increment $175

D9243Intravenous moderate (conscious) sedation/analgesia – each 15 minute

increment$142











ADA CODE









operative visit)$64

















analysis$100









permanent tooth$75
















Effective January 1, 2017






ADA CODE



(anterior)$240































































D2975 Coping $350


ADA CODE









development$152























































ADA CODE






D4273



graft

$910








D4278



same graft site

$425

D4283




$683

D4285




$584



D4346Scaling in presence of generalized moderate or severe gingival inflamation --

full mouth, after oral evaluation$138

























teeth)$1,052


teeth)$1,052


and teeth)$750


ADA CODE









































metal)$900











metal)$1,233


(predominantly base metal)$1,220


metal)$1,000



metal)$890






ADA CODE


D6081


single implant, including cleaning of the implant surfaces, without flap entry

and closure

$170









maxillary$1,200


mandibular$1,200



















































removal)$137


ADA CODE


D7210



indicated

$234





complications$486






displaced tooth$417
















D7350




$675





cm$500


1.25 cm$700










tissue$157



















ADA CODE






increment$141











ADA CODE

CDT 2016 DESCRIPTION ALLOWABLE








operative visit)$64














D0290Posterior - anterior or lateral skull and facial bone survey radiographic

image$85




analysis$100









permanent tooth$75














Effective July 1, 2016






ADA CODE




(anterior)$240
































































ADA CODE


D2975 Coping $350








development$152






















































ADA CODE







D4273



graft

$910








D4278



same graft site

$425

D4283




$683

D4285




$584



























teeth)$1,052


teeth)$1,052


and teeth)$750



ADA CODE








































metal)$900











metal)$1,233


(predominantly base metal)$1,220


metal)$1,000



metal)$890







ADA CODE








maxillary$1,200


mandibular$1,200



















































removal)$137

D7210



indicated

$234





ADA CODE



complications$486






displaced tooth$417
















D7350




$675





cm$500


1.25 cm$700










tissue$157






















increment$141



ADA CODE











Documents

Confidential and Proprietary - Regence BlueCross ... Periradicular surgery without apicoectomy $591 ... Gingivectomy or ... bounded spaces per quadrant $196 D4240 Gingival flap procedure,