2020/12/16 Council Agenda Packet

D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3430 D3450 D3920 D3950 Endodontic therapy, molar (excluding final restoration) Treatment of root canal obstruction; non -surgical access Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Internal repair of perforation defects Retreatment of previous root canal therapy - anterior Retreatment of previous root canal therapy - premolar Retreatment of previous root canal therapy - molar Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) Apexification/recalcification - interim medication replacement Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) Apicoectomy - anterior Apicoectomy - premolar (first root) Apicoectomy - molar (first root) Apicoectomy - (each additional root) Retrograde filling - per root Root amputation - per root Hemisection (including any root removal), not including root canal therapy Canal preparation and fitting of a preformed dowel or post 5. Periodontics D4210 Gingivectomy or gingivoplasty - 4 or more contiguous teeth or tooth bounded spaces per quadrant D4211 Gingivectomy or gingivoplasty - 1 to 3 contiguous teeth or tooth bounded spaces per quadrant D4240 Gingival flap procedures, including root planing - 4 or more contiguous teeth or tooth bounded spaces per quadrant D4241 Gingival flap procedure, including root planing - 1 to 3 contiguous teeth or tooth bounded spaces per quadrant D4249 Clinical crown lengthening - hard tissue D4260 Osseous surgery (including elevation of a full thickness flap and closure) - 4 or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) - 1 to 3 contiguous teeth or tooth bounded spaces per quadrant D4263 Bone replacement graft - retained natural tooth - first site in quadrant D4264 Bone replacement graft - retained natural tooth - each additional site in quadrant D4270 Pedicle soft tissue graft procedure D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth or edentulous tooth position in graft D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) D4277 Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth or edentulous tooth position in graft D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth or edentulous tooth position in same graft site D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) — each additional contiguous tooth or edentulous tooth position in the same graft site D4341 Periodontic scaling and root planing - 4 or more teeth per quadrant D4342 Periodontic scaling and root planing -1 to 3 teeth per quadrant D4346 Scaling in presence of generalized moderate or severe gingival inflammation — full mouth, after oral evaluations D4355 Full mouth debndement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth Current Dental Terminology (CDT) 0 2020 American Dental Association. All rights reserved. $125 $0 $0 $0 $75 $100 $125 $125 $0 $0 $75 $100 $125 $0 $0 $125 $125 $0 $150 $65 $150 $150 $150 $150 $150 $0 $0 $150 $150 $150 $150 $150 $150 $65 $65 $0 $0 $0 001 L-WA811(5/20) 25